CARE HOMES FOR OLDER PEOPLE
The Manor House Hall Lane Old Farnley Leeds West Yorkshire LS12 5HA Lead Inspector
Ann Stoner Unannounced Inspection 7th February 2006 9:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Manor House Address Hall Lane Old Farnley Leeds West Yorkshire LS12 5HA 0113 231 0216 0113 2310216 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Chamkaur Singh Dhaliwal Mrs Manmohan Kaur Dhaliwal Mrs Irene Foster Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th July 2005 Brief Description of the Service: The Manor House is a converted stone building that has been extended to provide residential care, without nursing, for older people. The home is located west of Leeds, adjacent to the local park, with a housing estate and bus routes nearby. There are 22 single and 4 shared rooms over two floors. A shaft lift gives access to the second floor. There are four communal lounges, separate dining space, three bathrooms and one shower room. Toilets are near to the lounge areas and bedrooms. The gardens are well maintained with outdoor seating areas. The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was announced and took place on the 12th July 2005, a further visit was carried out on the 16th September 2005 to monitor progress with care plans. There have been no further visits until this unannounced inspection. The purpose of this inspection was to monitor progress in meeting the requirements and recommendations made at the last inspection and to look at the standard of care for people living in the home. This inspection was carried out by one inspector between 9.30am – 5.15pm. The people who live in the home prefer the term resident therefore this will be used throughout this report. During the inspection, I looked at records, I saw staff carrying out their work and spoke with residents and staff. Feedback at the end of the inspection was given to the deputy manager. Comment cards/questionnaires are left for residents, visitors and other professionals at each inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection (CSCI). Comments received in this way are shared with the provider and/or the manager, without revealing the identity of those completing them. Since the last inspection none have been returned. What the service does well: What has improved since the last inspection?
The home has made an effort to address many of the requirements and recommendations made at the last inspection. The home carries out a thorough pre-admission assessment to make sure that it can meet the needs of the person, before any decision about admission is made. There has been some improvement to care plans; these now give staff background information about the resident up to the point of admission.
The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 6 Medication is ordered in a way that reduces the risk of mistakes, it is stored properly and the home has bought a small fridge for medicine that needs cold storage. Staff wear protective clothing when serving food. This reduces the risk of cross contamination and cross infection. Floor covering in the laundry has been replaced and the walls have been replastered. This makes cleaning more effective. Ways of laundering soiled linen has improved, which again reduces the risk of cross infection. Blinds have been fitted to the window in the conservatory. The stair carpet has been replaced and water temperatures are regulated to prevent the risk of scalding. The owner now keeps a record of his monthly visits to the home and a copy is sent to the CSCI. All complaints are recorded along with a summary of any investigation, the outcome of the complaint and any further action needed. What they could do better:
The home must try to improve records so that care staff know the precise level of care that should be given. Risk assessments must be completed so that staff know the measures that should be taken to keep the resident safe. A record must be kept of all accidents and a copy should be held in the resident’s care file. When an accident is not witnessed by staff, a record should be kept of when the person was last seen and by whom, so that any patterns or trends are identified. Some changes are needed to the way that the home records medication. Some carpets and floor covering needs replacing and broken tiles need replacing in some bathrooms and toilets. Rusty commode chairs must be replaced, freestanding bedroom furniture must be secured, all divan beds must have a headboard, and valances should be fitted. A number of issues must be addressed to prevent the spread of infection in the home. These include liquid soap and paper towels being provided in all areas of the home. The sluice room must be kept clean and tidy. Colour coded cleaning cloths must be used. Cleaning staff must wear protective aprons and gloves. The clinical waste bin must be pedal operated. There must be better separation between clean and dirty linen in the laundry. Good hygiene practices must be followed in the kitchen at all times. Staff must attend training that is relevant to the conditions of the residents. Training must also include food hygiene, moving and handling and infection control. Staff must have a minimum of 3 paid training days a year. The home must develop a training plan which shows when staff attend training and when
The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 7 further training is due. A minimum of 50 of care staff must have a National Vocational Qualification (NVQ) at level 2 or above in Care. Recruitment procedures must improve to make sure staff employed are suitable and safe to work with the residents. Staffing levels must be reviewed and sufficient staff must be employed so that care and management staff do not have to carry out cleaning and cooking tasks. The home must make changes to the way it records the staff rota, so that it is easy to identify the senior person in charge of the shift. Staff meetings must take place and a quality audit system must be introduced. Residents must have access to their records at all times, and records must be available for inspection. A number of requirements and recommendations have been made to address these issues. These can be found at the end of this report. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 5. Residents do not move into the home until their needs have been assessed. Residents and/or their relatives can visit the home before deciding about admission. EVIDENCE: The care records of three residents were sampled, and in all cases there was an assessment of need carried out by a social worker. The home also carries out a pre-admission assessment, which in all cases was extremely detailed and showed that information from a variety of sources had been considered. Care plans confirmed that residents visit the home before admission. A detailed record of the visit is kept in the care plan, along with a review and outcome of the visit. The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 9 & 10. Care plans have improved, but these must be developed further to make sure that all of the residents’ needs are met. Some medication practices increase the risk of mistakes, and the recording system does not allow an audit to be carried out. Information about residents is not always secure, which compromises their privacy and breaches legislation. EVIDENCE: Care plans have improved and in those care plans sampled there was an excellent pen picture of the resident. Some plans were more detailed than others, for example one person’s plan for oral hygiene was very detailed giving staff clear instructions on the precise level of assistance required. However, this person had a history of depression but there was no mental health care plan and no leisure care plan. Information from a detailed assessment about monitoring food intake was overlooked because there was no dietary care plan. Another person had a good continence care plan, but after a fall in the home, a care plan, about how to prevent further falls, was not put in place. One person’s care plan referred to ‘wandering’, but there was no exploration as to whether he was wandering because he was bored, or disorientated.
The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 11 There were no falls risk assessments or nutritional assessments in care plans. Moving and handling assessments did not show the identified need and care plans did not include the methods to be used, the number of people to be involved and the aids that should be used for each transfer. The home uses a risk assessment format where risk is scored on a scale of 1 – 4, but this does not identify the specific risks involved, or the actions to be taken to minimise the risk. The risk assessments are not reviewed. Daily records showed that a resident was found on the fire escape at 3am; there was no follow up action recorded and a risk assessment showing the measures taken to prevent this from happening again had not been completed. Handwritten entries made by staff on medication administration records (MAR) are not signed by the person making the entry, the amount of medication received is not recorded and the entry is not checked and countersigned by a second person. The home receives a 7 day supply of medication from the pharmacy, but the MAR is in place for a 28 day period. Only the first week of medication is shown as being received by the home, making it impossible to carry out an audit trail from the MAR over a 28 day period. There were omissions on the MAR for several residents, and it was not clear whether the medication had given. Staff were able to describe how they respect the privacy and dignity of residents, such as knocking on bedroom doors before entering, and closing bedroom curtains when assisting residents to wash or dress. However, information about residents including their name, date of birth, GP, and hospital appointment cards were on view on a notice board in a corridor This issue, which contravenes The Data Protection Act, was identified at the last inspection. A number of requirements have been made. The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents are able to make choices. EVIDENCE: Residents confirmed that they could choose what time they go to bed at night and get up in the morning. Staff described the choices available to residents, and understood the importance of residents being in control of their lives. The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. EVIDENCE: The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 & 26. A review of the home is needed to make sure that residents live in a safe, comfortable and well maintained environment. Infection control is not properly managed; which increases the risk of infection in the home. EVIDENCE: Some parts of the home were being decorated during the inspection. A new stair carpet has been fitted, but a major review of furnishings and fittings is needed with a clear timescale for action. There were broken tiles and ill-fitting floor covering in one ground floor toilet. Tiles were missing in a first floor bathroom. The first floor corridor carpet is threadbare and a carpet in one bedroom is so thin, the shape of the floorboards is clearly visible. This carpet is also slippery, which creates a major slip hazard. One bathroom on the first floor needs painting, the woodwork on the window ledge needs attention and tiles need grouting. Some tubular commode chairs are rusty, not all divan beds have a headboard, valances are not fitted, and one freestanding wardrobe was unsteady and the door did not close properly.
The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 15 Liquid soap and paper towels are provided in most areas of the home, but most of the soap dispensers were empty. A member of the domestic staff was seen cleaning toilets without protective clothing. She later said that she does not wear aprons or gloves, and does not use colour-coded cleaning cloths as recommended by Environmental Health. This person has had no training in infection control or COSHH (Control of Substances Hazardous to Health). The clinical waste bin in the sluice room was dirty, and was not pedal controlled. The sluice room is also used as a storeroom for toiletries, cleaning materials and cleaning equipment. Clean linen is stored in the laundry, separated only by a shower curtain. All of this creates a serious risk of cross infection. A number of requirements have been made to address these issues. The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 29 Training and staffing levels do not meet the needs of the residents and staff recruitment does not protect residents. EVIDENCE: Staffing levels are inappropriate for the layout of the home and the number of residents. There is only one cook, who works 6 days a week from 8am – 1pm. This means that care staff have to carry out kitchen domestic tasks and then prepare and clear away the teatime meal. In the absence of the cook, the manager or her deputy works in the kitchen. Night staff prepare vegetables and raw meat, which is unacceptable. Not only does this take care staff away from their caring duties, it increases the risk of cross infection in the home. There is only one domestic employed, which again is inappropriate for the layout of the home, and means that at weekends care staff have to carry out some cleaning tasks. Although the home was clean there was an offensive odour in some rooms. The rota does not clearly show: • • • the job roles of individual staff members the senior person in charge of the shift any additional duties carried out by care staff. Staff work a two week rota. Copies of the rota are not retained after the two week period. The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 17 The current staffing levels do not allow any flexibility for staff to attend training and staff do not have a minimum of three paid training days a year. The deputy manager said that staff are reluctant to attend external training events. Some staff have started a distance learning course on infection control and medication, but they are experiencing difficulties with their external assessor. Approximately 20 of staff have completed an NVQ (National Vocational Qualification) at level 2 or above in Care. There is no training and development plan; therefore there is no system of identifying when mandatory training updates are required. There was no recruitment documentation in one staff file, such as an application form, references, CRB/POVA (Criminal Record Bureau/Protection of Vulnerable Adults) check, interview records or photograph. The deputy manager said she thought these might be locked away elsewhere but was unable to locate them. In another file there were a number of discrepancies relating to a visa, passport details and references. There were no recruitment records for the handyman, and he confirmed that he has not had a CRB/POVA check. A number of requirements and recommendations have been made to address these issues. The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38. The home is not properly managed because the manager and the deputy manager regularly carry out catering and other non-management tasks. Quality assurance systems are in place but these should be developed further so that an effective improvement plan can be produced. Residents do not have information about, and access at all times, to any money held on their behalf. The health and safety of residents and staff are compromised by some practices. EVIDENCE: The manager has a National Vocational Qualification (NVQ) level 4 in management. Dedicated management time for both the manager and the deputy is reduced because of the need for them to carry out cooking and caring duties. The manager does not attend any Care Home and/or manager’s
The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 19 peer support meetings that could keep her up to date with current practices. The deputy manager said that staff meetings do not take place, mainly due to the conduct of staff in these meetings. If any information needs to be shared with the staff team it is done on an individual basis. There is no quality audit of services and standards within the home, other than the distribution of annual questionnaires to relatives, other professionals and residents. The distribution of this questionnaire is now overdue. The home does not analyse feedback or use comments in a structured way to improve services. At the time of this inspection the manager had been on holiday for almost 4 weeks. During this time the deputy manager, at her request, has had no access to the safe contents, which contain records of transactions and money held on behalf of residents. The deputy manager had been left a ‘float’ and said that she was keeping receipts of all transactions from this pot of money. This practice is unacceptable. The deputy manager said that fire alarms are tested at a different point each week, but this is not shown on the fire record. The last recorded fire drill was carried out in January 2005. COSHH (Control of Substances Hazardous to Health) risk assessments are completed for some products, but not for those bought at a supermarket, such as washing up liquid. The deputy manager said that risk assessments for safe working practices are being developed. Accidents forms were not completed for all accidents and those that were completed were not kept in the resident’s care plan. If staff do not witness an accident, no record is kept of when the person was last seen and by whom. Accident records are not analysed on a monthly basis to identify and patterns or trends. Staff complete food hygiene training by a distance learning pack, but this method lacks assessment from a suitably qualified person. Some care staff were seen in the kitchen wearing protective clothing worn when assisting residents with personal care. Staff were seen to walk through, and use the kitchen as a shortcut to other parts of the home, and one care worker kept her handbag and newspaper on a kitchen worktop. The cook follows a cleaning schedule, but cleaning materials are stored next to chopping boards and other kitchen equipment. Vegetables are stored next to crockery and equipment such as weighing scales are worn and need replacing. A number of requirements and recommendations have been made to address these issues. The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X X X X 2 X 1 STAFFING Standard No Score 27 1 28 1 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 1 X X 1 The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement Care plans must set out in detail the action that needs to be taken by staff to make sure that all aspects of health, personal and social care needs of the resident are met. Care plans, wherever possible, must be signed and agreed by the resident and/or their relative or representative. There must be a review of the care plan at least once a month. Risk assessments must be in place for all areas of resident risk. These must show: • the specific risks involved • the benefits to the person by taking the risk • the actions to be taken to reduce the risk. Nutritional screening must take place on admission. Moving and handling assessments must show: • the methods to be used • the number of people to be involved
DS0000001479.V279839.R01.S.doc Timescale for action 30/04/06 2. OP7 13 (b) (c) 30/04/06 3 4 OP7 OP7 12 12, 13 31/03/06 30/04/06 The Manor House Version 5.1 Page 22 5 6. OP7 OP9 13 13 (2) the aids that should be used for each transfer. Falls risk assessments must be completed for all residents at risk of falls. All handwritten entries on MAR (Medication Administration Records) must be signed, dated, and show the amount of medication received. The entry must be checked and countersigned by a second person. This is unmet from 12.7.05. The MAR must show the amount of medication received from the pharmacy. • 31/03/06 01/03/06 7. OP18 13 (6) All medication record sheets must be fully completed in accordance with guidelines from the Royal Pharmaceutical Society of Great Britain. Nonadministration of medication must be explained. 31/05/06 All senior staff, including the registered provider, must complete training on the use of the multi agency adult protection procedures. Care staff must complete training on adult abuse and they must be made aware of their right to contact the Adult Protection Unit, independent of the home. This is carried forward from 12.7.06. The first floor corridor carpet must be replaced. The carpet in bedroom 1 – 2 must be replaced. Broken tiles in bathrooms and
DS0000001479.V279839.R01.S.doc 8. OP19 23 30/04/06 9. OP19 23 30/04/06
Page 23 The Manor House Version 5.1 10. 11. 12 13. OP19 OP24 OP24 OP26 23 23,16 13 13 (3) 14 OP26 13 (3) toilets must be replaced. Floor covering in the ground floor toilet must be replaced. Rusty commode chairs must be replaced. All freestanding wardrobes must be secure. Liquid soap and paper towels must be provided in all areas where clinical waste is handled. This includes bedrooms, bathrooms, toilets and the laundry. Toiletries must not be stored in the sluice room. The sluice room must be kept clean and tidy at all times. The clinical waste bin must be pedal operated. Colour coded cloths must be used as recommended by Environmental Health. Cleaning staff must wear protective aprons and gloves. There must be better separation between clean and dirty linen in the laundry room. 12/07/05 30/04/06 14/02/06 01/03/06 01/03/06 15 16 17 18. OP26 OP26 OP26 OP26 13 (3) 13 (3) 13 (3) 13 (3) 31/03/06 01/03/06 08/02/06 30/04/06 19. OP27 18 (1) (a) Clean linen must not be stored in this area. Staffing levels must be reviewed. 01/03/06 This is unmet from 12.7.05. The staff rota must show: • • • the job roles of staff the senior person in charge of the shift any additional duties carried out by care staff. 20. OP28 18 A copy of the actual rota worked, must be retained in the home. All staff must have a minimum of 30/04/06
DS0000001479.V279839.R01.S.doc Version 5.1 Page 24 The Manor House 3 paid training days per year. All staff must have up-to-date training on infection control, moving and handling, and food hygiene. A training and development plan must be developed to identify when mandatory training updates are required. Staff must complete training relevant to the needs of the resident group. The home must make progress to make sure that a minimum of 50 of the care team have a NVQ at level 2 or above. Staff must not be employed in the home until a CRB/POVA disclosure check has been returned. Recruitment files must contain a completed application form, two written references, evidence that a CRB/POVA check has been carried out and a photograph of the staff member. Staff meetings must take place on a regular basis, with minutes of the meeting kept for future reference. An effective quality audit system must be introduced to make sure that systems and services are reviewed and improved. Residents must have access at all times to any money that is held for safekeeping on their behalf. They must also have immediate access to their current balance and any transactions carried out. Records must be available for inspection at all times.
DS0000001479.V279839.R01.S.doc 21 OP29 19 Sch 2 19 Sch 2 08/02/06 22 OP29 01/03/06 23 OP32 21 31/03/06 24 OP33 24 31/05/06 25 OP35 17 Sch 4 20/02/06 26. OP37 17 Sch 4 20/02/06
Page 25 The Manor House Version 5.1 27. OP10OP37 17 All information relating to residents must be kept secure. Personal details must not be displayed on notice boards in corridors. This is unmet from 12.7.05 Risk assessments for safe working practices must be in place. An accident record must be completed each time a resident has an accident. A copy of the record must be held in the resident’s file. Staff must not enter the kitchen unless they are wearing protective clothing, such as a tabard, apron or white coat. Staff must not use the kitchen to access other parts of the home. All staff must attend fire drills and fire training at intervals of no longer than 6 months. Good food hygiene practices must be followed in the kitchen at all times. 12/07/05 28 29 OP38 OP38 13 17 Sch 4 31/05/06 08/02/06 30 OP38 13 08/02/06 31 32 33 OP38 OP38 OP38 13 23 13 08/02/06 31/03/06 08/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard OP24 OP29 OP32 Good Practice Recommendations Valances should be fitted to divan beds. All divan beds should have a headboard fitted. Staff files should contain records of the recruitment interview. This should be signed and dated by both people conducting the interview. The registered manager and/or the deputy manager should be given the opportunity to attend Care Home’s meetings
DS0000001479.V279839.R01.S.doc Version 5.1 Page 26 The Manor House 4 5 OP38 OP38 and/or manager’s support meetings. There should be a qualified first aider on each shift. Where staff do not witness an accident, a record should be kept of when the person was last seen and by whom. An analysis should be kept of all accidents so that any patterns or trends can be identified. Records of fire alarm tests should show which fire point has been tested. 6 OP38 The Manor House DS0000001479.V279839.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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