Inspection on 24/04/08 for The Manor House Lynmouth

This inspection was carried out on 24th April 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Manor House Lynmouth 05/10/09

The Manor House Lynmouth 28/10/08

The Manor House Lynmouth 19/11/07

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Manor House Lynmouth The Manor House Lynmouth Devon EX35 6EN Lead Inspector Jo Walsh Unannounced Inspection 10:00 24 and 29th April 2008 th 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 Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 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 Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Lynmouth Address The Manor House Lynmouth Devon EX35 6EN 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) 01598 752269 Mr Gordon Wilfred Watson Mrs Waltraut Charlotte Watson VANCANT POSITION Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 17. 19th November 2007 Date of last inspection Brief Description of the Service: The Manor is a detached Georgian property situated in a secluded position, in its own grounds, overlooking the sea at Lynmouth. It is within easy access of the facilities of Lynmouth. It is registered to accommodate up to 17 elderly people. Accommodation is provided in 13 single occupancy and two double occupancy rooms. The fees for accommodation at this home range from £281.00 to £372.00 per week. Additional fees are levied for items such as chiropody, newspapers, hair dressing and toiletries. Copies of previous inspection reports are available at the home. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 stars. This means the people who use this service experience poor quality outcomes. This is primarily due to the fact that the home currently does not have a registered manager in place and the registered providers do not have sufficient knowledge, skills or qualifications to manage the home. This key inspection was brought forward in light of several concerns expressed about the registered manager having left the home. It was completed over two days and took approximately 8 hours. During this time most of the people who live at the home were spoken to about the care and support they receive. Currently there are 7 people living at The Manor House, and all spoken to said they were happy living there. We also received 4 surveys from people who live at the home and their comments are included in the report. The registered manager left the service approximately six weeks ago without giving notice, leaving the new owners to deal with the day-to-day management and running of the home. Due to employment issues, they have been unable to advertise for a new manager, but have now received confirmation that they can proceed. We looked at a number of documents including plans of care, assessments, staff files, training records, menus and staff rotas. This information helps us to understand how well the home is meeting the national minimum standards. Prior to an inspection the home would normally complete an Annual Quality Assurance Assessment (AQAA), which gives us information about how the home maintains a safe environment, what training has been completed and tells us how they are reviewing their services to improve the care and support provided. Due to the inspection being brought forward, the registered providers did not have sufficient time to complete this, so for the purposes of this inspection we will refer to the previous AQAA the home submitted. What the service does well: The people who currently live at The Manor House say they are happy with the care and support they receive. Comments included • We are taken care of very well here • I am very happy to be here, I always consider myself very lucky to live here. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 6 The staff are very kind and understanding. The new owners are very nice and kind people. Support is offered in a respectful way and routines of the home try to reflect individuals’ choice and preferred routines. The home offers a good choice and range of meals that suit individuals’ likes and dislikes. Comments included • The meals are always lovely. • Should there be something I don’t like, I am given something else that I do like. • The food is very good, we get plenty of it and there is always a choice. Manor House is spacious and provides people who live there with a clean comfortable and homely environment. Everyone we spoke to said they liked the position of the home and their rooms. • What has improved since the last inspection? Some work has been undertaken to address the requirement made during the previous inspection about plans of care. Most people now have a plan of care that gives staff a basic understanding of individuals needs. There are very useful sections on individuals personal routines that could be further expanded to ensure care is delivered in a person centred way. The registered providers have employed more staff including a cook and three carers. They have ensured that all relevant checks were in place prior to them commencing employment, although staff files did not always make it clear the date of the start of employment. Medication records appeared better maintained and Mr Watson, registered provider has received training from the local pharmacist in safe handling, administration and recoding of medications. They now need to ensure that all other staff have this training completed to ensure that people who live at the home are protected by safe and robust medication practices and procedures. The registered providers continue to redecorate and refurbish areas of the home to improve the environment. When it was mentioned that soap dispensers and paper towels should be provided in communal toilets, the registered providers immediately ordered some to install. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 7 What they could do better: The registered providers must seek to employ a manager who is qualified and experienced in running a care home for older people. Without a manager in place new people should not be admitted into the home, either as permanent residents or for respite care. This is because the registered providers do not currently have the skills, experience or qualifications to fully assess the needs of any potential new people. Without good assessment processes in places both potential new people and existing people within the home could be placed at risk. Plans of care must include up to date risk assessments and provide sufficient information to show how staff should meet all assessed needs. Plans of care must be reviewed monthly and where possible should be developed and reviewed with the individual and/or their representative. This will ensure that care and support is delivered in a way that the individual wishes and prefers. All staff with responsibility of administering medication must have training by someone who is qualified and competent to deliver this training. This will ensure people are protected by a robust medication system and process. Where people are administering their own medications, the risk assessment for this needs to be kept under review as part of their ongoing care plan review process. The homes complaints procedure should be updated to include the commission’s new address and contact details. Checks on bath temperatures to ensure that the thermostatic valves are working correctly should be recorded along with any other regular maintenance checks. This shows how the home is maintaining a safe environment for the people who live there. The home needs to provide a separate sluice facility for commode pans, other than a communal bathroom, as this will help prevent any risk of cross infection. The laundry room must have a separate hand washing sink, from that of the sink used for sluicing soiled clothes, again to reduce the risk of cross infection. The step near the fire door on the first landing needs to be clearly identified, as this is a trip hazard. Although some training has been implemented, such as moving and handling and protection of vulnerable people and the Mental Capacity Act, further training is needed to ensure staff have the necessary skills to do their job effectively. This includes fire training, infection control and first aid to ensure The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 8 that a qualified first aider is available on the premises for all shifts, and the cook needs to update her basic food hygiene training. Induction training for new staff needs to be documented and be implemented form the day they start employment. This will ensure that they understand their role and responsibilities and keep people who live at the home safe. Staff files need to include the actual date of the start of their employment and a full employment history. 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 summary of this inspection report can be made available in other formats on request. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 9 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 Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Potential new people to the service could be at risk, as there is no one qualified or competent to fully assess people’s needs. EVIDENCE: We discussed at length the risks of offering a service to a new person without having completed a detailed and comprehensive assessment of need. The registered providers have agreed that they will not take any new people until they have management arrangements in place that ensure a qualified and competent person can complete assessments of need and show how these needs can be met. The registered providers had considered a referral to take someone for respite care, but have now agreed that without a detailed assessment this could place them, the individual and the existing people who live in the home at risk. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who currently live at the home have their personal, healthcare and social needs reasonably well met, however improvements are needed in plans of care to ensure that peoples needs and wishes are kept under review and risks are well managed. EVIDENCE: Most of the people who live at the home and those who returned surveys said they were very happy with the care and support they receive at The Manor House. Comments included • We are taken care of very well here • I am very happy to be here, I always consider myself very lucky to live here. • The staff are very kind and understanding. The new owners are very nice and kind people. Staff were observed to treat people with kindness and respect. Throughout the day individuals were asked if they were okay, did they need anything and there was a calm and relaxed atmosphere with staff chatting to people and including them in their coffee break time. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 12 Three plans of care were looked at in some detail. The registered providers said that one member of staff had been given the responsibility of getting care plans updated, since the departure of their manager. Clearly they had worked hard to try and make some improvements in the plans. Some had sections that included daily routines and preferences and this is commended as it gives staff good information to enable them to deliver care in a person centred way. Some areas still need further work. One person had a risk assessment for infection control in relation to their catheter. The assessment identified that the risk was very likely, but no actions had been identified as to how this risk was to be minimised. The registered providers explained that the district nurses came in on a regular basis to flush and change the catheter and that they could contact them should they need further advice. This information should be included in the risk assessment. This person’s plan of care identified that from the 10/06/07 a physiotherapist had recommended daily leg exercises, looking at the daily records over the last two week period there was no record of this being done. This was also identified in the last inspection report. Another plan had a risk of falls half completed, the assessment failed to identify whether the risk was low, medium or high and what steps should be taken to reduce any risks. This persons file also had a section ticked that said pain management, but there was no further details about what pain they had or how it should be treated. The assessment of pain management document had been left blank. This is insufficient detail to show how the home helps this person manage their pain, or indeed what pain they had. The third person’s plan of care had not been completed and many of the sections had been left blank. Some sections such as personal care had been started but was not signed or dated. All three plans had been reviewed or updated in January, but the form that was headed care plan review had been left blank. Plans of care should be reviewed monthly ideally with the person they concern. There was no evidence that plans of care had been developed or shared with the individuals they concern. Daily records and records of medical intervention were fairly well recorded, and showed that individuals health care needs were being well met. People spoken to confirmed that they were able to see their GP and some had regular visits from the district nurse team. The medication system and records were checked with the registered provider. The lunchtime medications being administered was also observed on the first day. The medications are stored securely and records were up to date. The book used for recoding controlled medications should have printed numbered pages on it to safeguard against anyone removing pages. This makes the The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 13 system much more robust. Since the last inspection Mr Watson, one of the registered providers has received training from the local pharmacist in the safe storage, administration and recoding of medications, and says he was informed this would now enable him to train the rest of the staff. We said that training in medications must be done by someone who was qualified and competent to do this so that the training can be verified. Any other staff member who has the responsibility of administering medications must as a matter of urgency complete this training. One person self medicates and they said they had lockable storage for their medications. The risk assessment for this individual needs to be reviewed on a regular basis, as part of the care planning process. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who currently live at The Manor House have their social needs met and routines of daily living are flexible to suit their needs and preferences. EVIDENCE: People spoken to and those who returned surveys said that there were some activities offered. One person said they had a singer a couple of times and they had really enjoyed this. Another person said they organised their own outings and activities, but did enjoy having a chat with the staff. During the inspection one staff member informed people they would be doing a bingo session over the weekend and the registered providers said they try to have regular activities and stimulation for the people who live there. It was agreed that they should keep a record of activities offered each week. The last inspection report highlighted the lack of staff interactions with people who live at the home. This is an area they have clearly improved upon. Staff were observed sharing their coffee break with one person, and chatting throughout the day to individuals, sitting and making sure they were comfortable. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 15 People spoken to said that they could have visitors whenever they wished, some people have their own phone line to stay in touch and post is received unopened. The routines of the home appeared flexible, with people choosing what time they got up. The staff handbook had a detailed daily routine for staff to follow and this included individuals’ personal routines about what time they preferred to get up, whether they liked a drink in bed etc. This is good practice ensuring that routines for staff are not simply task orientated, but take into consideration the wishes of the people they support. The home appears to offer a good choice and range of meals. People who live at the home said • The meals are always lovely. • Should there be something I don’t like, I am given something else that I do like. • The food is very good, we get plenty of it and there is always a choice. The menu records that a good variety of meals are offered, and alternatives can be provided if someone does not like or want the main menu choice. The home records any changes to menus and what alternatives are offered to people. As there are only 7 people currently living at the home they are able to offer a wide choice for teatime meals and individuals likes and dislikes are taken onto consideration when planning the menus. Bowls of fresh fruit were available in the lounge areas for people to have and biscuits were offered with drinks at regular intervals throughout the day. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals’ views and concerns are listened to and people were confident they would be acted upon EVIDENCE: The home has a stated complaints procedure, which should be updated to include the commission’s new address and contact details. The people spoken to and those who returned surveys were aware that they could make a complaint and knew who they should talk to if they had any concerns. One person said ‘’ we don’t need to make a complaint because everything is good here, if we did ask for anything I am sure they would sort it out.’’ The home have not received any complaints and the registered provider said they check with individuals every day to see that they are happy. The commission have received a number of concerns since the registered manager left. The concerns were around lack of staffing, which the providers have addressed by employing more care staff and a cook. The main concern expressed was that the providers do not have very much experience in managing a service for frail elderly people. One health care professional said that they were not overly concerned about the current people living at the home, because they did not have complex personal or healthcare needs, but would be very concerned if the home had any new residents who did have The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 17 more complex needs. This has been fully discussed with the registered providers and detailed in the section relating to assessments at the beginning of the report. Since the last inspection, staff has received training in the protection of vulnerable people, which enables them to understand abuse issues and what they should do if abuse is suspected. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manor House provides a clean homely and relatively safe environment for the people who live there. EVIDENCE: During this inspection a tour was completed of all communal areas and some of the individual bedrooms. The home is clean and fresh smelling. The registered providers have tried to ensure a homely environment with fresh flowers throughout the communal areas. They are also continuing with a programme of redecoration and refurbishment to ensure rooms are comfortable for people to enjoy. People who live at the home said they were happy with the environment. During the inspection the providers were advised that soap dispensers and paper towels should be provided in all communal toilets to help infection control and they immediately took action to order these. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 19 Further improvements would ensure a safer environment for both the people who live there and staff. Checks on bath temperatures to ensure that the thermostatic valves are working correctly should be recorded along with any other regular maintenance checks. This shows how the home is maintaining a safe environment for the people who live there. The home needs to provide a separate sluice facility for commode pans, other than a communal bathroom, as this will help prevent any risk of cross infection. The laundry room must have a separate hand washing sink, from that of the sink used for sluicing soiled clothes, again to reduce the risk of cross infection. The step near the fire door on the first landing needs to be clearly identified, as this is a trip hazard. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although recruitment practice is more robust, further training and support is needed to enable staff to provide care and support safely. EVIDENCE: The registered manager left without giving notice and some staff either left or were asked to leave, which meant for a time the home was operating on short staffing levels. The registered providers were having to cover many of the shifts themselves. They have addressed this issue by recruiting new staff. They have ensured that they gained the relevant checks on new staff before they started employment. The registered providers have managed to get some training completed such as moving and handling and protection of vulnerable people, but there are still gaps in the staff teams training that could leave them and the people they care for at potential risk. The registered providers must ensure as a matter of urgency that all staff with responsibility of administering medication must have training by someone who is qualified and competent to deliver this training. This will ensure people are protected by a robust medication system and process. Other training needed includes fire training, infection control and first aid to ensure that a qualified first aider is on for all shifts, and the cook needs to update her basic food hygiene training. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 21 Induction training for new staff needs to be documented and be implemented from the day they start employment. This will ensure that they understand their role and responsibilities and keep people who live at the home safe. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes does not have anyone who is qualified and competent to ensure the home is well run and managed. This could place people at risk. EVIDENCE: As previously stated the registered manager left without giving notice, leaving new owners who have had no previous experience in running a care home. The registered providers have tried to address some of the outstanding issues, the chief one being getting more staff employed so that they have sufficient numbers to meet the needs of the people who live there. Whilst they have achieved this, and ensured good recruitment practice by ensuring checks were completed, they have failed to ensure that new staff have a recorded induction programme. This could leave them, staff and people who live there at risk. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 23 We have asked that the home consider how they are going to manage the home in the interim of getting a suitable and qualified manager in place. Advice has been given as to what they could do, that in the short term they could seek an experienced manager from an agency, and we will be asking for them to provide us with a detailed action plan to tell us how they intend to meet regulations set out in this inspection report. Quality assurance systems were not checked during this inspection, as surveys had been used in October 2007, and the previous inspection report had given advice about how this could be improved upon. The registered providers have not had a chance to follow this up as yet. Areas of health and safety checks and some environmental issues have already been documented in the section relating to environment. The home has a fire risk assessment, which was not checked, but the home were advised to ensure that all staff had updated fire safety training. They also need to ensure that the induction programme is used and recorded for all new staff. The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 24 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 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X X X 1 The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 18(1)(c) Requirement As required from previous inspection: The registered person shall ensure that persons employed to work at the care home receive training appropriate to the work they perform. This includes ensuring all new staff have suitable time and support to complete induction training. (Last date set for compliance 31/01/08) The registered person should keep care plans under review, revise the care plan and notify the person of any changes in their care plan. (Previous date set for compliance 31/12/07) The step near the fire door on the first floor must be clearly identified so that it does not remain a trip hazard The registered provider must ensure that suitable arrangements are in place to prevent infection. This relates to having a separate sluice for DS0000070220.V363412.R01.S.doc Timescale for action 30/06/08 2. OP7 15(2) 30/06/08 3. OP19 13(4) a 30/06/08 4. OP26 13(3) 30/08/08 The Manor House Lynmouth Version 5.2 Page 26 5. OP7 15 6. OP27 18(1)(a) commode pans and separate hand washing facilities in the laundry area Plans of care must provide sufficient detail to show how assessed needs are to be met and include risk assessments with actions of how to minimise any identified risks The registered person must ensure that the home is staffed by suitably qualified, competent and experienced persons at all times, relevant to the numbers and needs of those who are residing in the home. This includes ensuring that staff have up to date training in fire safety, infection control, safe administration of medication and first aid. (Previous date set for compliance 31/12/07) The registered person shall ensure that persons working at the care home are appropriately supervised. (Previous date set for compliance 31/01/08) 30/07/08 30/06/08 7. OP36 18(2) 30/06/08 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 OP7 OP16 OP33 Good Practice Recommendations Those living at the home would benefit from being involved in the compilation of their care plans. That the home’s Complaints Procedure is amended to include the Commissions new contact details The registered person could develop the Quality Assurance DS0000070220.V363412.R01.S.doc Version 5.2 Page 27 The Manor House Lynmouth System by using open ended questions in order to obtain more relevant information for those who use the service and other stakeholders The Manor House Lynmouth DS0000070220.V363412.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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