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Inspection on 17/01/08 for The Manor House Nursing Home

Also see our care home review for The Manor House Nursing Home for more information

This inspection was carried out on 17th January 2008.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Anyone thinking of moving in to The Manor House can go and visit and have a meal so that they can see for themselves if the home is suitable. People are properly assessed before they move in. This makes sure that staff can meet their needs. Staff are quick to involve GPs and other health care professionals to make sure people`s health care needs are met. People living in the home said that the meals are good and that they always get a choice of meal. Relatives said that they are made to feel welcome and can stay and have a meal if they want to. The home is well maintained, clean and comfortable. This means it provides a good standard of accommodation for the people living there. Staff training is ongoing and staff are receiving appropriate training to make sure that they can do their job properly. We asked staff what they thought the home did well. They told us that people are well cared for, staff are caring and contentious, the home is clean and well maintained and the food is good.

What has improved since the last inspection?

Over half of the care staff have completed their National Vocational Qualification (NVQ) in care. This means that they are qualified and competent to look after people living in the home. Magnetic door closures are in the process of being fitted to bedroom doors. This means that people will be able to leave their doors open if they wish but the doors will close automatically in the event of a fire.

What the care home could do better:

Copies of the Service User Guide are available. However it is recommended that a copy of the service user guide is given to people who use the service or to anyone thinking of moving in. This will make sure that people have relevant information about what The Manor House Nursing Home provides.People must be given a contract or terms and conditions of residence document before, or on the day of, admission. This will make sure they are fully aware of their rights, responsibilities and the fees that are payable. Care plans need to be in place before or on the day of admission so that staff are clear about what care and support they need to give. Staff must be properly checked before they start work in the home to make sure they are suitable and safe to work with older people. Staff must tell us about certain things that happen in the home, so that we can check they are taking the proper action. Questionnaires and a comment book are available for people who live in the home and their relatives, however these are not well used. A formal quality assurance system must be put in place so that people living in the home and their relatives are consulted about how the home is run and are informed about the action taken in response to their suggestions.

CARE HOMES FOR OLDER PEOPLE The Manor House Nursing Home 127 Wakefield Road Lightcliffe Halifax West Yorkshire HX3 8TH Lead Inspector Paula McCloy Key Unannounced Inspection 17th January 2008 09:30m 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 Nursing Home DS0000001102.V358259.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 Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Nursing Home Address 127 Wakefield Road Lightcliffe Halifax West Yorkshire HX3 8TH 01422 202603 01422 204113 oliverjamesthomas@hotmail.com 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) Mrs Jean Thomas Mrs Angela Charlesworth Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Elderly patients over 60 years of age Date of last inspection 14th February 2007 Brief Description of the Service: The Manor House Nursing Home is a comfortable home providing nursing care for up to 31 older people. It is set in its own attractive, well kept grounds with pleasant outside seating for people to use in the better weather. There is plenty of car parking and the home is on a bus route. The bedrooms are a mix of single and shared rooms and the communal rooms are spacious and attractive. The home is well furnished and kept in good decorative order. The weekly charges in the home range from £425.50 to £453.00. Additional charges are made for hairdressing, chiropody and newspapers. The Manor House Nursing Home DS0000001102.V358259.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 1 star. This means the people who use this service experience adequate quality outcomes. The last key inspection took place in February 2007. Since then we have been back to the home once. That visit was made to look at a complaint that we received about the health and personal care of someone living in the home not being good and that the home did not respond to a complaint that was made by a relative. This inspection was carried out to assess the quality of care provided to people living at the home. The inspection process included looking at the information we have received about the home since the last key inspection as well as a visit to the home, which was carried out over one day and lasted approximately 7.5 hours. During the visit we spoke to seven people living in the home, 2 managers, 4 members of staff and 2 relatives. We also observed care staff delivering care, looked at various records and looked around the home. The home completed a self assessment form which provided us with some information about the service. We have used some of that information in this report. Comment cards were sent to 7 people living in the home, 7 relatives, 27 staff and 3 health care professionals; these cards provide an opportunity for people to share their views of the service with us. Information received in this way is shared with the home without identifying who has provided it. Five people living at the home, 6 relatives, 11 staff and 2 GPs wrote to us with their comments. Their comments have been used in this report. What the service does well: Anyone thinking of moving in to The Manor House can go and visit and have a meal so that they can see for themselves if the home is suitable. The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 6 People are properly assessed before they move in. This makes sure that staff can meet their needs. Staff are quick to involve GPs and other health care professionals to make sure people’s health care needs are met. People living in the home said that the meals are good and that they always get a choice of meal. Relatives said that they are made to feel welcome and can stay and have a meal if they want to. The home is well maintained, clean and comfortable. This means it provides a good standard of accommodation for the people living there. Staff training is ongoing and staff are receiving appropriate training to make sure that they can do their job properly. We asked staff what they thought the home did well. They told us that people are well cared for, staff are caring and contentious, the home is clean and well maintained and the food is good. What has improved since the last inspection? What they could do better: Copies of the Service User Guide are available. However it is recommended that a copy of the service user guide is given to people who use the service or to anyone thinking of moving in. This will make sure that people have relevant information about what The Manor House Nursing Home provides. The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 7 People must be given a contract or terms and conditions of residence document before, or on the day of, admission. This will make sure they are fully aware of their rights, responsibilities and the fees that are payable. Care plans need to be in place before or on the day of admission so that staff are clear about what care and support they need to give. Staff must be properly checked before they start work in the home to make sure they are suitable and safe to work with older people. Staff must tell us about certain things that happen in the home, so that we can check they are taking the proper action. Questionnaires and a comment book are available for people who live in the home and their relatives, however these are not well used. A formal quality assurance system must be put in place so that people living in the home and their relatives are consulted about how the home is run and are informed about the action taken in response to their suggestions. 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 Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 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 Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 (Standard 6 does not apply) People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are assessed before they move in to make sure that the home can meet their needs. They can visit to see if they think the service is suitable for them. Some people are not given terms and conditions of residence, this means they do not get written information about the fees payable or their rights and responsibilities. EVIDENCE: We asked people living in the home if they had enough information about the home before they moved in. Everyone said that they did. The home has a brochure that they give to people that contains some basic information about The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 10 the home. Staff need to make sure that people also get a copy of the Service User Guide that will give people additional information about the service the Manor House provides. For example this document contains details of the home’s complaints procedure, the terms and conditions of residence document or contract and the qualifications and experience of staff. It is important that everyone living in the home and anyone thinking of moving in is given a Service User Guide. Five out of the six people living in the home that completed a survey told us that they had a contract or terms and conditions of residence document. We discussed this with the managers who said that only people living in the home who paid privately were given a contract. It is important that people who do not pay privately are given a terms and conditions of residence document before, or on the day of, admission. This will make sure that they are aware of their rights, fees payable and their responsibilities. The home’s admission procedures are good. The records for the most recent admission to the home showed that staff had completed the necessary assessment before she moved in. This means that staff are sure they can meet people’s needs before they move in. Staff said that they encourage people to come and look around the home, although often it is the relatives that do this. This gives people the opportunity to see the home for themselves and decide if it is suitable. The home does not provide intermediate care. The Manor House Nursing Home DS0000001102.V358259.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s health and personal care needs are being met. EVIDENCE: We looked at a selection of care plans because we wanted to see what individual needs had been identified and what action staff are expected to take to meet these needs. We asked people in the surveys if they get the care and medical support they need. People said that they did. One relative said ‘on the whole well cared for.’ The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 12 We looked at three care plans. We could see from these plans that people are receiving health care from a range of people such as doctors, tissue viability nurses, dentists and chiropodists. Details of any visits are clearly documented in the care plan together with any advice given. The two GPs that completed a survey felt that people’s health care needs are met. They said the following: Staff listen to residents concerns and try to help them.’ ‘Good follow up of medical conditions of residents.’ ‘Staff know people well.’ The care plans are detailed and set out what staff need to do to make sure that people’s needs are met. Risk assessments are in place and clearly show what action staff have taken in order to minimise any identified risks. For example, one person was identified as being at high risk of developing pressure sores. Her care plan details the type of bed and mattress to be used and that she needs to be repositioned frequently. There was evidence in two of the care plans we looked at of people or their relatives being involved in planning process. Care plans are reviewed every month and updated as necessary. In the surveys staff told us that they are given up to date information about the needs of people living in the home. Staff made the following comments: ‘Care plans are in the staff office available to read up on care needs. There are also reports on new clients from the hospital or other care settings.’ ‘We are always kept updated.’ ‘We are always encouraged to read any relevant information about a service user that we would need to know in order to give the best possible care for that person.’ Care plans are not in place when people move in. The care plans we looked at had been written some time after people had moved in. Staff need to put a basic care plan in place, from the assessment information before or on the day people move in. The plan can then be added to as staff get to know people. This will make sure staff know what care and support they need to offer when people first move into the home. In July 2007, we visited the home to look at complaints from a relative regarding poor personal hygiene, a person’s loss of mobility and not having enough to drink. We found from talking to staff, other professionals and from looking at the records that staff had offered proper care and support for the person concerned. The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 13 There were 25 people living at the home when we visited. There are 8 people being nursed in bed who are dependent upon staff to meet all of their needs. There are also 5 people who need assistance from staff when they eat or drink. Staff said that they are busy throughout the day to make sure people’s needs are met. The manager needs to monitor the levels of dependency in the home to make sure there are always enough staff on duty to meet people’s needs. People all looked smart and well cared for. People told us that they have their hair done regularly. We did not observe a medication round. We looked at the medication records, which showed that people are receiving their medication at the right times. Staff are re-typing the medication records instead of using the medication administration records provided by the pharmacist. This is introducing a risk that information may not be copied accurately. For this reason staff must use the medication administration records that the pharmacist supplies. Staff also need to make sure that there are photographs of people with the medication records so that it is easy to identify the person the medication is for. The Manor House Nursing Home DS0000001102.V358259.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are some activities on offer to keep people stimulated. Meals at the home are good offering both choice and variety. EVIDENCE: We looked at four care plans. There were life histories on two of the care plans, which give staff valuable information about those people. Staff need to continue to add this information to all of the care plans. There was some information on the care plans about how people like to spend their time and what they enjoy doing. This helps staff to provide appropriate activities. We asked people living in the home if activities are arranged in the home for them to take part in. People said sometimes. People said that they enjoyed the visiting entertainers. The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 15 In the morning we saw that staff had no time to spend with people unless they were offering direct care. There was music playing in the conservatory and a number of people were reading the daily newspapers. In the lounge the television was on and staff checked with people what they wanted to watch. There was some good humoured banter between people living in the home and various members of staff that was clearly enjoyed. Staff said that they have time to sit with people in the afternoons and talk or arrange group activities. Staff are considerate and thoughtful. One person that is being looked after in bed likes to watch television. Staff had made sure that her bed had been turned at an angle so that she could easily see the television. Relatives said that they are made to feel welcome when they visit. One person said that they have their meals at the home on a regular basis, which they enjoy. The home has a nice dining room, which people are encouraged to use. There is a choice of food for every meal. People living at the home said the food is good and that they enjoy the meals. People who need help at meal times were assisted by staff appropriately. The Manor House Nursing Home DS0000001102.V358259.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 & 19 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living in the home know who to talk to if they are unhappy or want to make a complaint. Staff training and policies protect people from abuse. EVIDENCE: Since the last inspection in February 2007 we have visited the home once to look at a complaint we received. We did not find any problems with the care at the home but did find that the relative had written a complaint directly to the home that was not responded to using the home’s complaints procedure. The owner did contact the social worker for the person concerned to try and arrange a meeting with the family to discuss their complaint, however, no meeting took place. The registered manager accepts that she should have responded to the complainant in writing letting them know what she was going to do about their concerns. We asked people living in the home, and their relatives, if they knew who to speak to if they were not happy and if they knew how to make a complaint. Everyone said that they did. The complaints procedure is on display on the notice board. This needs to be updated to include the timescales within which people can expect a response to any complaint that is made. There is a The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 17 complaints log in place where details of any complaint that is made can be recorded together with the action taken and outcome. No complaints have been recorded. In the surveys we asked staff if they knew what to do if a person living in the home or their relative had any concerns. All of the staff said that they did and made the following comments: ‘Information for staff and relatives is displayed on the notice board.’ ‘Reassure them as much as I can and refer them to the manager or owner.’ ‘Report to the owner of the home and she will address accordingly to the situation.’ In the self assessment document we were told that all staff have received adult protection training and that the home has a ‘whistleblowing’ procedure in place. This means that staff are aware of the adult protection procedures and how to deal with any concerns that may arise. The Manor House Nursing Home DS0000001102.V358259.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): 19 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People live in a clean, well maintained and comfortable home. EVIDENCE: The home is in Lightcliffe and is set in its on extensive, well kept grounds. There is plenty of car parking and it is on a bus route. In the self assessment document we were told that work is ongoing to meet the requirements of the fire safety officer. New magnetic door closures are being fitted to the bedroom doors so that people will be able to leave their door open if they wish, but it will close automatically if the fire alarm sounds. The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 19 The home is clean, comfortable and tidy. People living at the home confirmed that this is always the case. The self assessment document told us that infection control procedures are in place and that staff have received infection control training. There have been no outbreaks of any infectious disease since the last visit in February 2007. The Manor House Nursing Home DS0000001102.V358259.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, 28, 29 & 30 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Staff are well qualified and experienced and people using the service like them. The home’s recruitment process is poor. This is leaving people at risk of being cared for by staff who are not suitable and safe to work with older people. EVIDENCE: At the time of this visit, there were 25 people living in the home. The duty rotas showed that, during the day, there is one nurse on duty with 3 care assistants in the morning and one nurse and 2 care assistants at night. In the surveys staff said that they felt there were usually enough staff on duty to meet people’s needs. The manager is aware that she needs to keep the staffing levels under review as people are admitted to the home or if people become more dependent. Staff recruitment practices are poor. At the last inspection in February 2007 a requirement was made about this. The home was told that they must make sure that a protection of vulnerable adults check (POVA), criminal records bureau check (CRB) and two written references are obtained before staff start The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 21 working in the home. On this visit we found that staff have started working in the home before the necessary checks have been completed. We looked at three staff files and found that all three staff had started work before their POVA check had been obtained. One of the files also only contained one written reference. At the very least staff must have a POVA check and two written references before they start work. They may then only work if supervised until their full CRB check is received. We have written to the owner about this. Without a robust recruitment procedure there is no guarantee that people in the home are cared for by staff who are suitable and safe to work with older people. Staff told us in the surveys that they had a good induction when they started work in the home that covered everything they needed to know to do the job. They also told us that they are being given on going training that helps them to understand and meet the needs of people living in the home. They made the following comments: ‘Every question was answered with reassurance I could talk openly if any problems arise.’ ‘I feel I can discuss any new training courses I hear about.’ ‘They are always willing to listen to any requests for training.’ The self assessment document told us that there are 19 care staff working in the home, 10 have completed their NVQ (National Vocational Training) level 2 or 3 in care. There are two more staff who are working towards this award. This means that staff are trained and competent to do their job. The people living in the home that we spoke to said that they like the staff and find them helpful, pleasant and caring. The Manor House Nursing Home DS0000001102.V358259.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, 35 & 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is generally well managed however some systems must be improved and developed to make sure that the home is run in the best interests of the people who live there. EVIDENCE: There is a registered manager who is a nurse. She takes responsibility for the management of the care and works in a very ‘hands on’ way with the people The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 23 living in the home. She is supported by the owner and management team, who also work at the home. In the surveys staff told us that they feel supported by the manager. Staff made the following comments: ‘I always feel comfortable to ask the manager about any issues regarding work.’ ‘My manager is often at work on an evening and I can discuss any issues I have regarding my work in care.’ The Annual Quality Assurance Assessment (AQAA) was returned to us after a reminder letter was sent out. All sections of the AQAA were completed and the information gave us a reasonable picture of the current situation within the service. The evidence to support the comments made was satisfactory, although it would have been useful to have more information about how it was planning to improve the service. In the AQAA the home told us that they believe they meet the staff recruitment standards. At the last key inspection that took place in February 2006 we told the home that they must make sure that pre-employment criminal records bureau checks, protection of vulnerable adult checks and two written references must be obtained. On this visit we found that all of the necessary checks on staff had not been completed before staff had started working in the home. The home are not managing staff recruitment properly and this is leaving people at risk of being cared for by staff who are not suitable or safe to work with older people. There are certain things that the home need to tell us about. We call these ‘notifications’. For example the death of anyone living at the home and any accident in the home that people need medical treatment for. Although we have received notifications about deaths at the home we haven’t received any others. We discussed this following the inspection. Staff said that the notifications have been sent by post. We have checked our records and these show that we have only received notifications about deaths at the home. It is important that the home let us know about certain things that happen so that we can check they have taken the right action. There are no formal quality assurance systems in place. In the self assessment document the home told us that ‘we speak with service users and their families. For the most part, residents are unable to contribute in this regard, many of their needs having to be anticipated. Those who are able to comment for themselves are complimentary and satisfied.’ Staff said that they had sent out surveys in the past but had received a poor response. There are questionnaires and a comments book available for people The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 24 to complete but these are not well used. The home needs to look at ways of showing how they are consulting people about the way the home is run and how they respond to any suggestions they receive. Staff do not hold any money for safekeeping for people living at the home. People are invoiced separately for any additional services they have such as hairdressing and chiropody. The self assessment document showed that equipment is serviced regularly. We looked at the fire test records and found these were up to date. This means that the system is working properly. The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 25 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 2 1 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 2 The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 26 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 OP2 Regulation 5 Requirement Timescale for action 28/02/08 2 OP7 15 3 OP9 13 4 OP29 19 People living in the home must be given a terms and conditions of residence document before or on the day of admission. This will make sure that people know about their rights and responsibilities. A basic care plan must be in 28/02/08 place for people before or on admission. This will make sure that people’s needs are identified and met. The medication records that are 14/02/08 supplied by the pharmacist must be used. This will make sure that medication is given as prescribed. Pre-employment CRB and POVA 14/02/08 disclosures must be received and two written references obtained for all new staff. This makes sure that people in the home are cared for by staff who are suitable and safe to work with older people. (previous timescale of 09/07/07 not met) The home must have formal DS0000001102.V358259.R01.S.doc 5 OP33 24 30/04/08 Version 5.2 Page 27 The Manor House Nursing Home 6 OP38 37 quality assurance and monitoring systems in place. This will make sure that the service is reviewed and people are consulted about the way the home is run. The home must make sure that 07/03/08 they make reports to us about any notifiable incidents. This will make sure that we can check they have taken appropriate action. 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 Refer to Standard OP1 Good Practice Recommendations A copy of the service user guide should be provided to anyone considering moving into the home and all the people who currently live there. The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. Extracts may not be used or reproduced without the express permission of CSCI The Manor House Nursing Home DS0000001102.V358259.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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