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Inspection on 08/11/06 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 8th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

The manager made sure that prospective residents had enough information to help them to make a choice about whether the home was right for them. Residents were assessed before admission. This meant that staff understood what care the person needed and whether they would be able to provide it. Residents said they were looked after very well and received medical care if they needed it. A relative described the care as "first class," and another commented that the standards of care were very high. The home matched up to residents` expectations. One resident said "I am quite content here," and another said "it suits me fine." Several residents commented that the staff were; "very kind", "patient," "marvellous," and one said, "they do their best for us." Relatives also said the staff were "very attentive." Residents said the staff respected their privacy and helped them to keep their independence. One resident said that her room was her "private space, my own little home." Residents were happy with their daily lives and routines. One said that the home was "very easy going" and another said, "We are not tied to times." There was a programme of activities to occupy residents` time and some said they enjoyed the games and other activities and always joined in. One resident commented that they were all kept busy. Residents were satisfied with the visiting arrangements, which meant they could see relatives and friends at any time. There were strong links with the local community and residents participated in events in the village. Most of the comments about the meals were positive. One resident wrote, "the food is highly recommended." Residents had opportunities to tell the management what they liked or did not like about the home. They could make suggestions for improvements if they wanted to. Residents said they knew who to talk to if they were not happy with anything and several said that they were sure that the management would try to sort out any complaints for them. The home was nicely decorated and furnished. Residents were able to personalise their bedrooms with pictures, ornaments and small pieces of furniture. A resident commented that the home was "cosy." There were enough staff on duty to make sure that residents got the care they needed. In order to protect residents, the manager made sure that all staff had thorough background checks before they started work at the home. New staff had a good level of training to make sure that they understood their roles and existing staff were encouraged to attend courses. Over half of the staff had a nationally recognised qualification in care. Residents and visitors said that the home was well run. One visitor commented that the home was in a different league and the whole ethos came from management down. Fire safety equipment and electric and gas systems were serviced regularly. This helped to make the home safe for the people who lived and worked there.

What has improved since the last inspection?

There had been some improvements in the way staff managed residents` medicines but some further improvements were still needed to lessen the risk of medication errors.

CARE HOMES FOR OLDER PEOPLE The Manor House Nursing Home Bridge Road Chatburn Nr Clitheroe Lancashire BB7 4AW Lead Inspector Jane Craig Key Unannounced Inspection 09:30 8th November 2006 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 DS0000022504.V308370.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 DS0000022504.V308370.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Nursing Home Address Bridge Road Chatburn Nr Clitheroe Lancashire BB7 4AW 01200 441394 01200 440507 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) www.manorhousechatburn.co.uk Mr Chris Harrison Mrs Janet Harrison Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability (19) of places The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Under Annex 2, a max of 19 service users requiring Nursing Care who fall in the category of either OP or PD A maximum of 31 service users requiring personal care of the category of OP Staffing for service users requiring nursing care will be in accordance with the Notice issued dated 3 August 2001 7th March 2006 Date of last inspection Brief Description of the Service: The Manor House Nursing and Residential Home is privately owned by Mr and Mrs Harrison. The home is registered to provide long or short term care for up to 31 residents, nineteen of whom may have nursing needs. The Manor House is a converted 17th Century property situated in the village of Chatburn. It stands in large, well maintained gardens with patio areas. There are parking spaces in the grounds. The home is close to local amenities such as the Post Office, village hall, churches and pubs. The local bus service to Clitheroe is nearby. The home comprises two floors. There is a passenger lift and a stair lift providing access to bedrooms on the upper floor. Other aids and adaptations are available to assist service users to move around the home independently. There are twenty eight single bedrooms and two shared rooms. Twenty rooms have en-suite facilities. There are accessible bathrooms and toilets on both floors. There are three lounges, a large conservatory and two dining rooms. The communal spaces are furnished in a homely way and to a good standard. Information about The Manor House is sent out to prospective residents when they enquire about admission. Copies of the latest CSCI inspection report were on display at the entrance for residents to take as they wished. At 8th November 2006 the fees ranged from £366.00 to £810.00 per week. There were additional charges for newspapers, hairdressing and some therapies. There was a fee for staff escorts to appointments and private transport. The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at The Manor House on the 8th of November 2006. At the time of the visit there were 27 residents accommodated. The inspector met with a number of residents and spent time observing interactions between staff and residents. Wherever possible residents were asked about their views and experiences of living in the home and some of their comments are quoted in this report. Nine residents and ten visitors had completed questionnaires before the inspection. Their views have been taken into account when writing the report. Discussions were held with the registered provider / manager, two members of the management team and four care staff. The inspector also spoke with three visitors. A tour of the premises took place and a number of records and documents were viewed. This report also includes information submitted by the home prior to the inspection visit. What the service does well: The manager made sure that prospective residents had enough information to help them to make a choice about whether the home was right for them. Residents were assessed before admission. This meant that staff understood what care the person needed and whether they would be able to provide it. Residents said they were looked after very well and received medical care if they needed it. A relative described the care as “first class,” and another commented that the standards of care were very high. The home matched up to residents’ expectations. One resident said “I am quite content here,” and another said “it suits me fine.” Several residents commented that the staff were; “very kind”, “patient,” “marvellous,” and one said, “they do their best for us.” Relatives also said the staff were “very attentive.” Residents said the staff respected their privacy and helped them to keep their independence. One resident said that her room was her “private space, my own little home.” Residents were happy with their daily lives and routines. One said that the home was “very easy going” and another said, “We are not tied to times.” There was a programme of activities to occupy residents’ time and some said they enjoyed the games and other activities and always joined in. One resident commented that they were all kept busy. Residents were satisfied The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 6 with the visiting arrangements, which meant they could see relatives and friends at any time. There were strong links with the local community and residents participated in events in the village. Most of the comments about the meals were positive. One resident wrote, “the food is highly recommended.” Residents had opportunities to tell the management what they liked or did not like about the home. They could make suggestions for improvements if they wanted to. Residents said they knew who to talk to if they were not happy with anything and several said that they were sure that the management would try to sort out any complaints for them. The home was nicely decorated and furnished. Residents were able to personalise their bedrooms with pictures, ornaments and small pieces of furniture. A resident commented that the home was “cosy.” There were enough staff on duty to make sure that residents got the care they needed. In order to protect residents, the manager made sure that all staff had thorough background checks before they started work at the home. New staff had a good level of training to make sure that they understood their roles and existing staff were encouraged to attend courses. Over half of the staff had a nationally recognised qualification in care. Residents and visitors said that the home was well run. One visitor commented that the home was in a different league and the whole ethos came from management down. Fire safety equipment and electric and gas systems were serviced regularly. This helped to make the home safe for the people who lived and worked there. What has improved since the last inspection? What they could do better: Care plans did not always tell staff about all of the residents’ needs and what type and amount of care they should be receiving. Plans were not always kept up to date. This meant that staff may not always give the right care. Please contact the provider for advice of actions taken in response to this The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Manor House Nursing Home DS0000022504.V308370.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 DS0000022504.V308370.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process ensured that residents had sufficient information to help them to make a decision about moving in and staff had enough information to understand the new resident’s care needs. EVIDENCE: Residents who completed questionnaires said that they received enough information about the home to help them make a decision about moving in. Most residents said they, or their families, had a contract. Prospective residents were assessed before they were offered a place at the home. Staff said they received enough information to understand the resident’s needs and start to plan their care before they were admitted. Residents received written confirmation that their assessed needs could be met at the home. Intermediate care is not provided at the Manor House. The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 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, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs were met in accordance with their wishes. Medication practices safeguarded residents. EVIDENCE: The care plans for three residents were inspected and others were viewed in less detail. The standard of the plans varied. Some were very specific to the individual and provided staff with enough detail to ensure that care was provided in a consistent way. Others had not been reviewed and they contained inaccurate or out of date information. None of the residents had a detailed plan to assist with personal care but those residents spoken with said they received the help they needed in the way they preferred. There was evidence that residents or their relatives were consulted about the plans. Care plans included risk assessments for moving and handling, nutrition, pressure sore risk and falls. Plans were generally in place where a risk was identified. A wound chart and nutritional risk assessment for one resident were not up to date but there was other evidence to show that the care had The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 11 been carried out. There was evidence that residents’ healthcare needs, including psychological healthcare needs, were monitored. Residents were referred for specialist care when required. Residents spoken with said they were very well looked after and one relative described the care as “first class.” The majority of residents who filled in questionnaires indicated that they always received the care and medical support they needed and all of the relatives indicated they were satisfied with the overall care provided at the home. The policies and procedures for managing medication had been reviewed. They were on display in the treatment room to ensure that staff could easily refer to them. Residents who administered their own medication had assessments in place. There were complete records of medicines received but some discrepancies in the records of medicines disposed of. There were no gaps on the Medication Administration Record (MAR) charts. Handwritten entries were signed and witnessed but staff did not always re-write MAR charts following dosage changes, and abbreviations were used to indicate how often the medicine was to be given. Criteria for “when required” medicines were recorded for each individual and variable doses were indicated. Storage was clean, tidy and secure. Storage, recording and administration of controlled drugs were appropriate. From discussions with staff it was evident that they had a good understanding of the core values and gave examples of how they respected residents’ privacy. During the course of the visit staff were seen to speak to residents sensitively and with respect. Residents confirmed that this was always the case. One resident talked about how staff maintained her privacy when helping her with personal care. A relative also said it was, “very noticeable the respect for dignity, for example, going to the trouble of making sure they are tidy and clothes are co-ordinated.” The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had choice and control over their daily lives. Daily routines and meals suited residents. The organised activities met most residents’ social and recreational needs. EVIDENCE: Residents who completed questionnaires and those spoken with during the visit said that the home organised a programme of activities. Some said they regularly joined in games, quizzes, movement to music and other groups. Others said they preferred to read or watch TV. One resident said, “I’m not one for games and things so they don’t try to force me.” On the day of the visit staff were observed spending time on a one to one basis with residents who were not able to participate in the planned programme. The staff on duty said that this always happened but there was nothing in the care plans to ensure that other staff provided the same level of stimulation. A relative confirmed that staff spent time going through their mother’s photo album and talking to her about it. Staff also helped residents to write out a brief summary of their social history if they wished to. Information about residents’ preferred daily routines, and religious or cultural needs were recorded on their assessments but not necessarily transferred to care plans. Residents confirmed that there were no set rules in the home and The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 13 they had choices about where and how to spend their time. One said, “I please myself about getting up, we’re not tied to times.” Another said, “they don’t keep a check on you, it’s an open house.” Most residents were able to make their own choices on a day to day basis. For example, one resident said they liked to spend most of their time in their room and another said they went out three or four times a week. Staff said that they used written information or consulted relatives in order to make choices on behalf of less able residents. There was an open visiting policy. Visitors all said they felt welcome in the home and could see their relative in private. One visitor said, “they treat visitors very well, it’s not just a narrow focus they have the knack of caring about the whole family.” Residents had strong links with the local community. Neighbours were invited to join residents to celebrate any special events and some residents attended local churches and groups. Residents’ comments about the meals were generally positive. They were satisfied with the variety, choice and quality. Comments included; “the food is highly recommended,” “very tasty,” “the food’s very good, suits me” and “meals are very good.” The records of meals showed that residents received a nutritionally balanced diet. Some repetition was noted in the menus but staff said that residents had been consulted. The dining rooms were attractively arranged with full place settings. Equipment was available to help residents to maintain their independence and staff were observed giving assistance to residents in a sensitive manner. The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 14 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints were taken seriously and acted upon. Staff understood adult protection issues, which safeguarded residents and meant that any alleged incidents would be dealt with appropriately. EVIDENCE: The complaints procedure was displayed. Residents also had access to a concerns and grumbles book. Records showed that even minor concerns were investigated and action taken. Residents and relatives who completed questionnaires indicated that they knew who to speak to if they were not happy and they knew how to make a complaint. During the course of the visit residents said that if they had any complaints they would speak to one of the managers. One resident said, “staff in the office are brilliant for helping you.” Another said “if there was anything, I’d only have to mention it and they would put it right.” Staff had access to written guidance on safeguarding adults and the manager confirmed that all had received refresher training. The staff spoken with during the inspection were aware of their roles and responsibilities in reporting any allegations to their line manager or outside the home. Although there was room for misinterpretation in the procedure, the management team were clear about how to deal with any suspected incidents. One resident told the inspector, “They make me feel safe.” A relative said they had complete confidence that their relative was safe. The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 15 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and well maintained. The standard of décor and furnishings provided residents with a safe, comfortable and homely place to live. EVIDENCE: There was a programme of routine maintenance and the home looked to be in a good state of repair. Each room was audited at least annually and areas were identified for redecoration and refurbishment. There was a good standard of décor and furnishings throughout the home. Residents were happy with their rooms, many of which were personalised to a high degree with ornaments and pictures. Residents commented that they were comfortable and one said the home was “cosy.” Work was underway to build a large extension to the home. Although several residents mentioned the building work they all said they were not inconvenienced by it. Since the last inspection a telephone network had been installed which meant that all residents had a handset and could contact each other’s rooms or receive outside calls. For an extra charge they could have an outside line activated. The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 16 The home was clean, tidy and fresh smelling. Residents who completed surveys indicated that it was always like that. The laundry was sited in the basement and away from resident areas. It was adequately equipped for the size of the home and on the day of the visit it was tidy and organised. There were no complaints about the laundry. One resident said she put her clothes in for washing at night and got them back the next day. Another resident commented that the laundry was very good. Staff had received infection control training and had access to infection control procedures. The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient staff and the majority held a relevant qualification. Recruitment practices provided safeguards for residents. EVIDENCE: The manager said that staffing levels were flexible because they were calculated on the number and dependencies of the residents. Duty rosters showed that there were extra staff rostered at peak times. The majority of the residents and visitors, who completed questionnaires, indicated that they thought there were enough staff on duty. At the time of the visit a resident said, “there are plenty of staff, I only need to buzz and they are there for me.” A relative said that there was “a good staff to resident ratio.” Staff themselves said they often had time to sit and talk with the residents as well as carry out personal care. Residents and visitors who completed questionnaires were positive about the staff. Those spoken with during the inspection described the staff as kind, caring and patient. A relative talked about the attitude of the staff and said there was never a sense of tension. Another relative wrote that the staff were “so kind and caring always with a smile.” The files of three recently employed staff were inspected. All the required preemployment checks were carried out and the required documents were on file. The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 18 All new staff had evidence of an initial induction which, according to the manager, was carried out over 3 days whilst the member of staff was supernumerary. Following this initial orientation, inexperienced care staff were mentored through the common induction standards. Other care staff completed part of the programme and registered nurses were assessed as to their competence to lead a shift. The training matrix showed that refresher training in the safe working practice topics was up to date and the manager confirmed that this was accurate. Staff said that training opportunities were very good. Those spoken with said that all their mandatory training was up to date and they had also attended short courses in health and care related topics. The manager stated that approximately 80 of care staff were qualified to NVQ level 2 or above. Other staff had commenced training and were attending weekly sessions at the home. The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 19 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, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a well run home. Residents have opportunities to influence the development of the home. Health and safety policies and practices safeguard residents and staff. EVIDENCE: One of the registered providers managed the home on a day to day basis. A management team, who each took responsibility for a different area of the service, supported her. In addition to holding two nursing qualifications, the registered person was qualified to NVQ level 4 in management. Her training profile evidenced that the registered person attended a wide range of courses designed to update both clinical and managerial skills. Residents said that the home was well run. A relative described the home as “in a different league” and said “the whole ethos comes from management down.” The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 20 Residents had opportunities to make their views about the home known. A member of the local community chaired regular residents meetings. Resident surveys were sent out annually and there was a suggestions book that was used by residents. Records showed that any comments were acted upon. Staff meetings were held every six months and staff were asked to complete surveys every year. The management team carried out audits on a number of procedures and practices, for example, infection control, accidents and manual handling. The staff did not handle any finances on behalf of residents. Those residents who were able, were encouraged to manage their own money and their families acted on behalf of others. Any expenditure for residents over and above the fees was paid by the home and residents or their families were billed every three months. Accurate records were kept of all transactions. A fire officer had recently audited the home and developed a new fire risk assessment. The registered person had taken action to meet recommendations following the audit. Recommendations following a recent Environmental Health inspection had been actioned. Servicing and testing of the fire system, equipment and alarms was up to date. Staff had received fire safety training and been involved in practice drills. Information provided by the registered person indicated that the servicing and maintenance of installations and equipment in the home was up to date. However, the records of portable appliance tests were not clear enough to be able to make a judgement as to whether all appliances had been tested. There was at least one accident and injury to a resident that had not been reported on appropriately. The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 21 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 X N/A 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 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 2 The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15(1) Timescale for action The registered person shall, after 31/12/06 consultation with the service user or a representative, prepare a written plan as to how the service user’s needs in respect of health and welfare are to be met. The plan must be kept under review and revised as necessary. (Timescale of 30/06/06 not met) There must be a complete record of medicines disposed of. 10/11/06 Requirement 2. 3. OP9 OP38 13(2) 17(1) Schedule 3 (3)(j) The registered person must keep 10/11/06 a record of any accident affecting a service user. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 23 1. OP9 MAR charts should be re-written to reflect changes in medication. Abbreviations should not be used on MAR charts. Medication, including dressings, no longer in use should be disposed of and appropriate records kept. 2. OP38 The registered person should bring the records of portable appliance tests up to date and address any shortfalls. The Manor House Nursing Home DS0000022504.V308370.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 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 DS0000022504.V308370.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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