Inspection on 06/02/08 for The Manor House Residential Home

This inspection was carried out on 6th February 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Manor House Residential Home 30/03/09

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Manor House Residential Home 137 Manor Road Littleover Derby DE23 6BU Lead Inspector Claire Williams Unannounced Inspection 6th February 2008 10:00 The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 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 Residential Home DS0000071036.V356651.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 Adults 18-65. 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 Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Residential Home Address 137 Manor Road Littleover Derby DE23 6BU 01332 372358 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) the_manor_house@hotmail.co.uk The Manor House Residential Home Alan Nathan Leask Care Home 11 Category(ies) of Learning disability (11), Sensory impairment registration, with number (11) of places The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The provider may provide the following category of service only: Care Home - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD Sensory Impairment - Code SI. The maximum number of service users who can be accommodated is: 11. This is the first inspection. 2. Date of last inspection Brief Description of the Service: The Manor House was registered on 30th October 2007. The building used to be a domestic dwelling that has been renovated and extended to meet the requirements of a residential care home. The home is registered to provide personal care and accommodation for eleven people of either sex aged 18 and over with sensory impairment and learning disabilities. The physical environment of the home includes 8 single bedrooms on the ground floor and 3 large bedrooms on the first floor. Access to the first floor is by stairs only. All rooms have en-suite facilities, and emergency call systems. The home has a sensory room, which is located on the ground floor in the conservatory. There is an accessible landscaped garden and patio areas. In addition to the en-suite facilities there is a communal bathroom with a jet spa bath equipped with an electronic ceiling hoist. The service provides people with a combined Statement of purpose and Service user guide. Information provided by the service stated that the current fees ranged from £650- £698.00 per week. Information is provided in the Statement of purpose/Service user guide of the services that are included in these fees. The Manor House Residential Home DS0000071036.V356651.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. This service was registered in October 2007 and this is the first key unannounced inspection, which took place over a period of a one-day. This inspection report is based on all the information we have received since the Registration, which includes the registration report and recommendations, the completed Annual quality assurance assessment, (which is completed by the provider or manager and is an opportunity for them to demonstrate how they meet the National Minimum Standards) notifications, and the unannounced site visit for the purposes of this inspection. All key standards identified by the CSCI were assessed during this visit. At the time of the visit The Manor House had five people living at the care home. The experiences of three people was followed during this inspection through a method called case tracking; this involved looking at their individual file and making a judgement about the quality of care they are receiving, and if their needs are being met. Some of the people that live in this service had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being supported by staff. Written documentation was examined to support the judgements made in this report and there was a tour of the building. The Registered manager was on duty and supported with the inspection visit. The inspector was supported on this inspection by an expert. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. Throughout this report ‘we’ refers to the Commission for Social Care Inspection. What the service does well: People are provided with written information about the home and can visit to see if it’s the right place for them. People are assessed by a professional and by the manager of this home so that a decision can be made on whether the home can meet their needs. People said the following about the staff “they are kind and supportive and they help me in the way I want them to”. People access community facilitates and spend time with their friends and family who can visit them in the home when they want. The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 6 People said they liked the food in this home and confirmed that they have a choice about what they eat. People said they are supported with respect and dignity, and liked living in this home. The building is spacious, homely and people have access to a sensory room for relaxation. What has improved since the last inspection? What they could do better: 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 Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 1, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with sufficient information about the Home in order for them, and their relatives, to make an informed decision about whether the service is right for them. EVIDENCE: In the providers self assessment they said they would ensure all prospective indivduals are assessed prior to admission. Trial visits are promoted, and individuals can view pictures of the home by accessing their web site. All individuals will be provided with a Statement of Purpose/Service User guide. Following the needs assessment the manager will take into consideration all the needs and aspirations of the prospective person to ensure that the placement at The Manor House will be successful. At this inspection the service demonstrated that they do provide people with the following information; combined statement of purpose/ service user guide and a contract. These documents are currently available in a written format only, but it was reported that plans are in place to make them accessible in accordance with the needs of the people that have moved into the home. People had copies of the Statement of Purpose/Service User guide in their bedrooms. It was reported that people have undertook trial visits to the home in order to make an informed decision about moving into this service. However no records had been completed to support this or how these visits were The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 9 responded to. There was evidence in three people files to support that professional assessments had been obtained before they moved into the home, and written confirmation was sent to confirm that the service could meet their needs. The manager had completed his own pre-admission assessment but the detail provided was not sufficient enough to identify the support needs of the individual, or the capability of this person with the people living in the home. The current assessment was aimed at providing information for the costing of the service for that individual. The manager intends to review this document. The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 6, 7, and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Person centred information was not in place for people that use this service. Therefore staff do not have the required information in order to deliver individualised support. EVIDENCE: In the providers self assessment they said they will develop a care plan for the individual, and encourage their involvement where able, along with family, friends, advocates, and any other health care professionals, and the care plan will reflect the decisions, preferences that the individual has stated. Once the care plan is drawn up, it will be reviewed at 72 hours after admission with the individual along with family, friends, advocates, and any other health care professionals, and reviewed at least every six months. They said people will be encouraged to lead an independent life style whilst at The Manor House and as part of their choice they will have the right to take risks whilst doing so. This will be managed by the risks being assessed and minimised as much as possible, and where possible the individual will be aware of the actions required by themselves to enable the risks to be The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 11 minimised. The files for three people were examined. The index for the care plan described the areas as problems and a discussion about this was held and the negative impact this could have about the person. Only one of these files contained information about the persons support needs and how these are to be met. The other files only contained the pre- admission information. This means that that person centred care cannot be delivered and that staff do not have access to sufficient information about the persons routines, preferences, and aspirations. Staff members spoken with stated that they receive a handover and verbal information is provided about each individual and their support needs, which enables them to provide the required support. From the discussions and observations held it was evident that they knew how to support people, but written records did not underpin their practice or approaches. It was reported that the support plans for these individuals are being completed on the computer and confirmation was received that these were put in place for staff to access two days following the inspection visit. The support plans that were in place did cover areas applicable to the needs of that person. They were written from the person’s perspective and did include the person’s preferences. However some of the detail in the support plans did not clearly identity the staff support required for example: for maintaining a safe environment it stated: staff support is required to maintain the bedroom and to access the community and cross the road. The type of support was not specified so it was not clear how staff should support these tasks. There was some information available to make staff aware of the decisions this person was able to make, but it was not explicit about what decisions they would require support with. There was limited information concerning diversity and equality issues. Although the plans were signed and dated by the manager there was no space for the person to sign their plan. In discussions with this person it was identified that they were able to sign their name with support. They confirmed that they were involved in the development of their plan. Following a review changes were made to provide a small kitchenette in the lounge area in their room, which the person said “this is very good as I can make my own drinks now in my room”. There was no evidence in any of the three files to support that assessments of risk factors had been completed, to support individual’s daily living choices. Observations supported that people were given choices in choosing how they wished to spend their day. The expert by experience asked a staff member how they communicated with people who were unable to express themselves verbally and the staff member stated: “we are in the process of learning methods of communication and they have a book with pictures which we can use when needed”. The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 11-17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices about their life style and are supported to develop their life skills. However this information is not written within peoples’ care plans, which could compromise the support provided. EVIDENCE: In the providers self assessment they said they will encourage all individuals to have the opportunity for personal development. They will do this by allowing people to continue to develop the skills they have, such as a particular hobby, domestic skills by encouraging people where possible to maintain there bedroom area, and staff to support them to continue to develop this skill. They will also ensure that service users have the continuing opportunities to fulfil their spiritual beliefs. There were support plans in one of the three files examined, which detailed the person’s activities, hobbies and aspirations. This person informed us that they still attend the activities and events they used to attend before moving into The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 13 this service. They also said they have been supported to continue their hobby of watching and taking trains rides. People have access to a sensory room, and individuals that were able to verbalise said they enjoyed this area. Staff support people to undertake variety of activities in the home including music, arts and crafts, and karaoke. People are also supported to access community facilities such as the local pub, groups, and disco’s. There was no information available in the other two files examined to inform staff of there likes and dislikes in relation to activities and hobbies. Individual routines were also not recorded. It was reported that some of the individuals attended day centres but as a result of moving into this service and due to funding, these placements are no longer available. A weekly activities schedule had not yet been developed for each individual living in this service. It was observed on the day that individuals who were at the home, watched the television and spent time in their room, or moving around the home. The expert by experience spoke with staff about the availability of activities and if people have choices about where they can go, the staff member said: “people do have choices to go to pubs, clubs, church and shopping. They normally use taxis, but the home will be getting a mini-bus soon”. The expert also spoke with a person who lives in the home and the following comments were made: “yes I do, like living here it is nice here. I have my own room upstairs with a small kitchen and can make my drinks myself when I want to. I have my own television but I have to get staff to turn it on for me. I like gardening and I go gardening on Wednesdays. I used to go on Tuesdays as well, but I got very tired. I also go to church on Sunday. I go by taxi on my own as the staff are busy with other things”. People had varying degrees of contact with their families. One person visits their family on a regular basis, and staff support other individuals to maintain contact if they are not able to do this independently. One person said there are no restrictions on visitors coming into the home, and they confirmed that they continue to regularly meet with friends. There was limited information available about whether people had any significant people in their lives or the support they may need to have opportunities to meet people and make friends or have personal relationships. The home employs a housekeeper and a full time cook. People are however still encouraged to maintain their bedrooms and it was reported that although the cook prepares all meals, individuals could still have the opportunity to make their own snacks. Observations at meal times supported that staff brought the food to individuals and staff stood waiting whilst people had their lunch. Individuals were encouraged to be independent but a staff member did The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 14 intervene to assist a person to eat more of their meal, although they were able to eat independently. The expert by experience interviewed a staff member who confirmed that a written menu was completed weekly offering a variety of meals including a takeaway evening, choices were available at each mealtime. There was some information in one person’s files of their food preferences; the other two files did not contain any information about this or the support they may require to eat or choose the food they eat. The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 18, 19, and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the person receives support in the way they prefer and require, the lack of information means this is not underpinned by detailed records that could compromise the support provided. EVIDENCE: In the providers self assessment they said they will ensure all individuals receive quality personal support and care, and have access to all relevant health care professionals. Their care plan will clearly indicate their identified requirements, and staff will contact or refer to specialist support should this be a requirement. A key worker system will implemented, and the staff will promote people’s independence and daily living on a daily basis as much as possible. Staff will monitor peoples identified health needs and ensure the contact details of any multidisciplinary team members involved is recorded in their care plan. As mentioned previously only one file contained a full support plan and supporting information. Therefore the healthcare needs for this person was recorded, as was any contact with healthcare professionals. This person said The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 16 that support was provided in a manner that suited their preferences, and that support was delivered with dignity and their privacy was respected. One support plan did state that this person should be weighed on a weekly basis. However only 2 dates were recorded on the weight chart, therefore this plan was not being followed. There was some information relating to the healthcare needs in the two other files examined but this mainly consisted of the contact details for healthcare professionals and the outcome of visits undertaken whilst living in this home. There was limited information available for staff on peoples preferred routines and preferences, and how they would like to be supported. However observations and staff discussions indicated that staff was aware of how to support these people. Confirmation was received that support plans covering these healthcare needs were in place two days following this visit. People’s medicines were being securely stored. The Medication Administration Record (MAR) sheets, relating to the case tracked people, were examined and found to be satisfactory. There were discrepancies in the way medication codes were being used, due to staff members using different practices. One page of handwritten medication instructions had also not been countersigned. A sheet of sample staff signatures and initials was in place to provide an audit trail. No controlled drugs were in use. The team leaders and manager administer the medication and it was reported that all of these staff had watched a medication DVD and answered the questions. It was reported that although visual observations of the staff practices had been undertaken a written assessment to support they are competent in these tasks had not yet been completed. One staff member was observed signing for medication before administering this to the person. The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 22 and 23 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Procedures for handling complaints and safeguarding were in place, ensuring that people are fully protected. EVIDENCE: In the providers self-assessment they said they have a complaints procedure in place, and all relevant people are given a copy. The procedure is displayed in the home, and a record of any concerns or complaints is kept. All staff have received safeguarding training and obviously recruitment checks are completed in line with the regulations to ensure people are safe guarded. In this assessment it was recorded that no complaints had been received and this was confirmed on the day of this visit. We also had not received any complaints for this service. The complaints procedure was displayed but in written form only and it was reported that an accessible procedure would be developed in the near future. Those that are able to communicate verbally said they would speak to the manager if they “were not happy”. It was reported that contact had been made with an Advocacy Service to arrange for an advocate to facilitate regular meetings to obtain peoples views. A copy of the local Multi-agency safeguarding procedures was in place along with internal policies and procedures in relation to abuse, whistle blowing, and support mechanisms. All staff had watched a DVD during their induction and completed the set questions and the completed records were seen. In discussions the staff they demonstrated their awareness of what action to take in the event of witnessing a potential abusive situation. There have not been any safeguarding adult investigations since registration. The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 18 Procedures are in place for physical and verbal aggression. An incident had been recorded in a persons log, but this had not been transferred to a monitoring or recorded as an official incident. A support plan for monitoring and managing this behaviour was not in place. People are supported to manager their own finances and for one person a support plan was in place for this. It was reported that systems and facilities are in place for the management of finances on people’s behalf but these were not examined on this occasion. The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 24, 25, 26, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely and comfortable environment that was well furnished and maintained. EVIDENCE: A site visit was undertaken as part of the registration process and the building was assessed as fit for purpose. The home was spacious and its corridors and rooms were large. People said they liked their room and one person who had a large room on the first floor has an additional small lounge area, which they were happy about. People have access to a sensory area, which is located in the conservatory, and sensory equipment was in place. People also had sensory equipment in their bedrooms. Bedrooms were personalised with people’s belongings. All bedrooms had numbers on them and these had not been personalised to enable people to assist them to recognise their room. People can access a secure large garden area, and people were observed using this during the visit. The Home is situated near to the town centre of derby, The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 20 and it was reported that transport will be obtained to enable people to access facilities. The expert by experience made the following comments about the building. “There are many doors in the home. These doors are heavy and not easy to open for most of the people. There are also markings on these doors and majority of the people are not able to read them. Pictures would have been better for the people, with touch panels for people using wheelchairs.” The service had a well-equipped laundry and the washing machine had a sluicing cycle. It was reported that the laundry was locked due to the chemicals stored in this room, which resulted in people dropping their washing by the door. One person had a support plan for accessing the laundry to enable them to do their own washing. All staff had undertaken, training in Infection Control. The Home was clean, at the time of the inspection, and there was no unpleasant odour in the Home. The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 32, 34, and 35. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. People were supported by staff who were appropriately trained and recruited to ensure their needs are met and are safe. EVIDENCE: In the providers self-assessment they said all staff recruited have covered all of the induction and foundation standards, and have full detailed job descriptions in place. All staff have received copies of the code of conduct, accompanied by the Manor House staff handbook. Staff were recruited to ensure they were competent to perform to the required expectations for their role. It stated that 40 of the staff team are working towards to a National Vocational Qualification (NVQ) to level 2 in care or above. The recruitment files for 3 of the most recently appointed staff members were examined. They were found to contain the majority of the information, required by the current Regulations. However one file did not contain identification for that person, one file did not contain a job description, and one file had only one reference. There was evidence to support that the three staff members had undertaken training from an organisation that said it meets the specifications of Skills for Care Common Induction Standards. Staff spoken to said that this training The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 22 enables them to have the skills and knowledge to fulfil their roles and “was a good training platform to work from”. Staff said that they have been provided with a booklet on makaton to enable them to learn this method of communication as some of the people living in the home use there own individual style of this sign language. All of the staff spoken to had experience of working with older people and this is their first time they have worked with people with a learning disabilities. People living in the home said, “the staff are friendly, and nice”. The service has been in operation for three months, and it was reported that formal supervision has not yet been received, but it was reported that daily practices are observed and informal supervision provided. There are plans for staff to attend formal training in relation to learning disability and person centred planning and many other service specific training. The staff team said they look forward to accessing many training opportunities and were motivated to further enhancing their skills and knowledge base. The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 37, 39, and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed to ensure the health safety of individuals is promoted and safeguarded. However the shortfalls in the care planning systems may result in people s needs not being fully met. EVIDENCE: In the providers self-assessment they said the Registered Manager is competent and qualified to meet the homes stated purpose. They will continue to develop the homes quality assurance and targets as they get more established, we have received cards from newly admitted individuals families stating thank you and at care reviews care managers and people have stated they are very happy. It was reported that systems would be implemented in order to obtain people’s feedback about the service, which include meetings, access to advocacy The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 24 services and quality assurance surveys. As stated in the provider’s assessment feedback has been obtained but none of these comments have been formally recorded apart from a few comments in peoples review notes. It was reported that meetings would be facilitated for people living in the home and their relatives in order to express their views and opinions about the service. The registered provider demonstrated that the building was fit for purpose and that all of the required health and safety checks had been carried out during the registration period. These were not examined on this visit. A fire risk assessment was in the process of being developed. The staff spoke positively about the Registered manager and described him as “supportive and approable”. They said that he works alongside them and advises them on any issues raised. They stated that he gave them a detailed overview of peoples support needs before they were admitted to the home, which enabled them to “provide appropriate support”. They felt that he provided “good leadership and direction”. Although the home is being managed appropriately, and people are not at direct risk, the shortfalls and lack of support plans available, could result in people needs not being fully met in a person centred way. This is a management responsibility and has potential implications for the people living in this home and the delivery of their care. The Manor House Residential Home DS0000071036.V356651.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 Adults 18-65 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 X 3 X X 3 X The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 26 N/a Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation Requirement Timescale for action 31/03/08 2. YA9 3. YA14 4. YA19 15(1)(2)(b) People must have a person centred care plan developed in consultation with them on admission to the home. This is to ensure staff can provide appropriate support and meet people’s needs. 14(2)(a)(b) There must be risk assessments 31/03/08 of peoples care needs or to support risks that people can take in their acre plan. These must be reviewed as needs change. This is to ensure that people are not exposed to avoidable risks, and to reduce any risk identified, which could adversely affect their health and well being. 16(2)(n) There must be information 31/03/08 about what activities people like and a planned weekly schedule developed to ensure people to engage in fulfilling activities. 13 (1) (b) People must have care plans in 31/03/08 place in relation to their healthcare needs, which are developed in consultation with the person on admission to the home. This is to ensure staff can provide appropriate support DS0000071036.V356651.R01.S.doc Version 5.2 The Manor House Residential Home Page 27 and meet people’s needs. 5. YA20 13(2) An assessment must be 30/05/08 undertaken of the staff member’s competency to administer medication. This is to ensure they are following the procedures and guidance. Staff must not be employed or 31/03/08 commence duties in the home until all of the required recruitment information has been obtained. This is to ensure people living in the home are safeguarded from any risks 6. YA34 19 and schedule 2 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 YA1 Good Practice Recommendations The Statement of purpose/Service user guide should contain all elements as required by the regulations, and be in an accessible format for the people who live in this service. The pre-admission assessment should be person centred and include a section about the persons compatibility with the people already living in the service. Written documentation should be completed of all the trial visits undertaken and how people respond to this visit. Information should be contained in peoples file to support the decisions made by them or by staff on the person’s behalf. This should be undertaken in accordance with the requirements of the mental capacity act. Staff should follow the medication procedure and Royal Pharmaceutical Society guidelines when administering medication. Staff should follow the same practice when using codes on the medication sheet. Staff should record all aggressive behaviour incidents on a monitoring chart, and a support should be in place to DS0000071036.V356651.R01.S.doc Version 5.2 Page 28 2. 3. 4. YA2 YA4 YA7 5. YA20 6. YA23 The Manor House Residential Home 7. YA34 direct staff on how to respond to situations and provide support to the person. Staff should access training in relation to working with people with learning disabilities, mental capacity act, and disability equality, to assist them to fulfil their roles. The Manor House Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Residential Home DS0000071036.V356651.R01.S.doc Version 5.2 Page 30 - 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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