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Inspection on 30/05/06 for The Manor Nursing and Residential Home

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

This inspection was carried out on 30th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 owner has recently appointed a new manager who has applied to be registered with the Commission. Comments received from staff about the new manager and systems she has put in place were very positive and the home has a calm and positive atmosphere, which is conducive to meeting the needs of those with dementia. The homes documentation is robust and consistent with meeting resident`s needs.

What has improved since the last inspection?

A new activities co-ordinator has been put in place who upon discussion with her appears to be innovative and interested in developing her skills to accommodate the resident`s needs and condition. The owner has invested in further decoration and re-carpeting of corridors, and stated that further decoration of rooms was imminent. The privacy and dignity of residents is respected, this was well evidenced through observation of staff at work. An administrator has been appointed to assist the new manager and ensure that she is more able to monitor clinical and care practise in the home rather than attend to routine administration. The owner is an equal opportunities employer and the staff group are from a variety of different countries including the new manager. The home had met the three outstanding inspection requirements.

What the care home could do better:

The care plans whilst containing expected information are still in some cases separated into two documents which could be amalgamated to be more easy to use and to present a day to day working document. Risk assessments and care plans should be updated and reflective of the current situation to ensure that safety and welfare is protected. The owner was advised to ensure that evidence of police checks of staff are held on their personnel files and available for inspection. This includes staffappointed from other countries. The owner should seek advice about when to renew police checks. The outcomes for residents might be improved if medication reviews were sought sooner. All incidents, which occur and affect the health, welfare or wellbeing of residents, should be reported to the Commission for Social Care Inspection without delay.

CARE HOMES FOR OLDER PEOPLE The Manor Nursing and Residential Home 78-80 Lutterworth Road Aylestone Leicester Leicestershire LE2 8PG Lead Inspector Mrs Gillian Adkin Unannounced Inspection 30th May 2006 10:00 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 Nursing and Residential Home DS0000001919.V296791.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 Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor Nursing and Residential Home Address 78-80 Lutterworth Road Aylestone Leicester Leicestershire LE2 8PG 0116 2990225 0116 2990257 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) themanorcarehome@hotmail.com Mr Bassir Jugon ** Post Vacant *** Care Home 49 Category(ies) of Dementia (49), Dementia - over 65 years of age registration, with number (49), Learning disability (23), Learning disability of places over 65 years of age (23), Mental disorder, excluding learning disability or dementia (23), Mental Disorder, excluding learning disability or dementia - over 65 years of age (23), Old age, not falling within any other category (49), Physical disability (49), Physical disability over 65 years of age (49) The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person may be admitted to the home who also falls within the category / combined categories MD, MD(E), LD, LD(E), when 23 persons who fall within any category / combined categories are already accommodated within the home. No person under 55 years of age who falls within categories DE, MD, PD or LD may be admitted to the home. 16th November 2005 2. Date of last inspection Brief Description of the Service: The Manor Nursing and Residential Home is a large establishment situated on the Lutterworth Road formerly a large house it has been developed and additional building added It is within easy reach of Leicester by public transport or car. The home offers accommodation for up to forty-nine residents with nursing, residential, mental health, and learning disability needs. The home also offers respite care facilities and is set in extensive mature gardens, which are mainly laid to lawn with shrub borders. There is a conservatory and also a covered area, which is occasionally used for activities or as a quiet area for visitors. The home has two dining room/ lounges. The home has a number of shared rooms and some bedrooms are en-suite. Both floors are accessible to residents by either a passenger or stair lift. All rooms are fitted with smoke detectors and nurse call systems. There are ample parking spaces and a number of local hotels and public amenities are within close proximity of the home. Current fees that apply: Nursing: £408-£453. Residential care: £375-425. Private: £ 450-550 The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service was inspected against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over 7.5 hours and commenced at 09.30 am on 30/05/06. The registered provider and acting care manager assisted during the inspection. The focus of inspections is upon outcomes for residents living at the home and obtaining their views of the service provided. This process considers whether the home meets the National Minimum Standards and highlights areas, which might need further development. The method of inspection used is called “case tracking’ which involved selecting five service users’ and tracking the care they received this was achieved by discussion with them (where possible) and looking at associated records. During this inspection a tour of the rooms (occupied by those case tracked) and associated communal areas took place and the inspector viewed internal records, and care plans. The inspector spoke to residents (where possible), nurses; care staff, the activities organiser, ancillary staff and the maintenance person. A visiting social worker also had discussion about one of the residents. Only one relative was available during this inspection for comments. Comments made about the home were positive. Engaging with many residents was predictably difficult however views were obtained where possible. Typical residents/relatives/ staff comments included: “ We offer the option of sitting at the table or in a lounge chair, this very much depends on the persons preference or mood at the time” “ We are conducting six reviews of care with social workers today” “I am trying to develop a new activities programme and have attended a Alzheimer’s Society training day to help me” “I am used to working with this client group and assist the staff where possible” “ I have a lovely room and the food is very good, I have no complaints1 “If I saw anything resembling abuse I would report it you an appropriate person” The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 6 “ I do not understand the term whistle-blowing and have not seen the policy” What the service does well: What has improved since the last inspection? What they could do better: The care plans whilst containing expected information are still in some cases separated into two documents which could be amalgamated to be more easy to use and to present a day to day working document. Risk assessments and care plans should be updated and reflective of the current situation to ensure that safety and welfare is protected. The owner was advised to ensure that evidence of police checks of staff are held on their personnel files and available for inspection. This includes staff The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 7 appointed from other countries. The owner should seek advice about when to renew police checks. The outcomes for residents might be improved if medication reviews were sought sooner. All incidents, which occur and affect the health, welfare or wellbeing of residents, should be reported to the Commission for Social Care Inspection without delay. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Manor Nursing and Residential Home DS0000001919.V296791.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 Nursing and Residential Home DS0000001919.V296791.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): 3.6 (Core standard 6 does not apply to this home Quality in this area is adequate. This judgement has been made using available evidence including a visit to the service. Resident’s needs are assessed before entering the home, attention to assessment of mental health needs would further improve the quality of care delivered. EVIDENCE: Five residents were case tracked and all care plans inspected included a detailed assessment and further evidence of ongoing reviews. An assessment was seen in the care plan of a newly admitted resident, which although comprehensive only identified their medical needs. The assessment was reflective of the person’s individual risks. It was not possible to establish if residents had been involved in assessments, however a social worker was observed in discussion with a resident whilst conducting a review of care. The acting care manager who is a qualified nurse said that she would be responsible for all assessments. The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 10 Some risk assessments had not been reviewed in two of the four care plans tracked and this was discussed with the owner and acting care manager. Behaviour management assessments were seen in operation in one care plan tracked. The Manor Nursing and Residential Home DS0000001919.V296791.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10 Quality in this area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans are detailed and address all healthcare needs. Outcomes would be improved by ensuring that regular evaluation takes place and action taken to address changes in needs. Medication is suitably and safely managed thus ensuring the safety and welfare of service users EVIDENCE: Five care plans were inspected and it was noted that all healthcare needs were addressed and that internal reviews were taking place. Three files appeared to contain a large amount of old/unrequired information. Some were not wholly reflective of the current situation with regard to continence management. The home is registered to care for people with very complex needs and two of the people case tracked were related, care records seen indicated that each persons needs had been considered in terms of their relationship. All necessary risk assessments were in place to address healthcare needs. The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 12 Social Care needs for residents were not detailed in care plans and discussion with staff indicated that the initial assessment did not include a social history. Diverse needs were addressed in three out of five plans inspected. Inspection of care records demonstrated some evidence of resident/ relative/advocate involvement. Nursing staff and the owner informed the inspector that they were involved in updating care plans. A falls risk assessment and handling risk assessment was seen on each file. One care plan contained a risk assessment for bedrails, which had not been updated since January 2005, the person concerned had had previous issues with falls and therefore it was considered important to review this assessment more often. Substantial evidence was seen in daily records of staff recording behavioural changes and subsequent referral to appropriate professionals. Reviews seen on care records indicated that relatives and funding authorities were satisfied with the care provided. The acting manager stated that she has put quality audits in place recently, which included the updating of information in care plans; evidence of this was seen in practice. Medication records were inspected in relation to those people tracked. Records seen indicated that medication prescribed was being administered appropriately. The residents were unable to clarify if medication was given as prescribed however discussion with the acting care manager and observation of a medication round indicated that medicines were appropriately administered. Several attempts were made to administer medication to a non-cooperative person, this was observed. Discussions with nursing staff and evidence provided demonstrated that medicines were reviewed six weekly although one resident tracked was noted to have refused pain relief regularly when being assessed as requiring this medication. This had not been followed up with the General Practitioner. Recommendations were made that the resident’s General Practitioner was called in to review the medication and refer to other professionals for support with managing medication when resistive. Nurses are fully responsible for administration of medication and evidence was seen on staff files of recent medication training. Discussions were underway with the pharmacist to provide training in medication for care assistants with a nursing qualification recently appointed from other countries. Observations of care and nursing staff indicated that residents are treated with respect and that choices are respected. The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 13 Evidence was seen in a shared room of appropriate screening in place. The Manor Nursing and Residential Home DS0000001919.V296791.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15 Quality in this area is good. This judgement has been made using available evidence including a visit to the service. The lifestyle experienced by residents appear to be appropriate to meeting their needs, further training of staff would enable them to manage difficult behaviours and manage needs more effectively. EVIDENCE: During this inspection it was observed that a volunteer worker was providing vital stimulation to residents’ by way of reminiscence therapy (war time video) and by singing wartime songs. Many residents were joining in and appeared to enjoy this activity. Discussion with this person indicated that she although she had not received formal training with persons who have dementia she had worked in the home for a number of years so had learned on the job. The activities organiser had recently commenced work at the home and discussion with her demonstrated that she was fully committed to providing appropriate enjoyable activities. Records seen identified that many residents enjoy board games and bingo. Two of the residents tracked enjoyed gardening and the inspector was shown potted plants outside they had done. The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 15 The activities organiser stated she had attended a recent dementia course and therefore understood resident’s needs. Discussion indicated that the assessment process did not include a social history, however and it was recommended to the owner that access to non confidential care records was given to the organiser in order for her to plan around individual needs and choices and to be aware of limitations. It was further recommended that a social history for each person be obtained during the initial four weeks of residency to allow appropriate activities to be incorporated in to the programme. Residents were observed being offered choices of meal at lunchtime and were offered a choice of place to sit. Drinks were offered regularly throughout the inspection. Routines of the home were observed and indicated that essential tasks are completed and routines maintained, taking into account the conditions of persons accommodated by the home (with dementia). Opportunities to wander around the home were observed without restriction although some particularly agitated residents were constantly requested by staff to “sit down” or offered “cups of tea” to pacify. It was recommended that staff are taught diversional techniques in order to prevent residents who wish to wander being placed in a position where they have their choice taken away. Staff training records seen did not include this type of training. The Manor Nursing and Residential Home DS0000001919.V296791.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are protected from abuse by robust policies and procedures and staff training. Outcomes would be improved by ensuring that support and guidance is obtained with management of difficult behaviours EVIDENCE: Concerns had been raised before this inspection by external professionals about staff’s approach and management of a particular resident. It was considered by them that staff had handled the person inappropriately when attempting to get this resident to move from a chair. Care plans of the person concerned were case tracked and evidence was found to suggest that this person’s behaviour had become more difficult at times to manage. Appropriate risk assessments were in place and evidence of behaviour monitoring was being kept. Observation of this person during the inspection confirmed that staff had to attempt different approaches in order to get them to respond to requests but mostly they were met with resistance. The inspector attempted to talk to the individual but was told to “go away” Discussion with staff and the owner stated that behaviour changed on a regular basis, but that they were aware of the frequent mood changes and how The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 17 to manage them. The inspector questioned if the persons reluctance to move might be associated with pain (identified in care assessment). The owner stated she would address this with the General Practitioner and request a referral to a psychiatric nurse for assistance in managing the resistive behaviour. A complaints book was seen in the foyer of the home and the last recorded complaint was in 2005. Accident records seen demonstrated that appropriate action had been taken following a fall for a resident tracked. Discussion with staff including a volunteer demonstrated their awareness of how to manage alleged abusive situations and records on staff files demonstrated that training had been given in house. Discussion with a new member of staff took place and it was evident from discussion that they were unfamiliar with the term “whistleblowing”. Discussion with the owner and acting manager indicated that they were aware that some staff did not fully understand some terminology used in policies and intended to address this at supervision. Policies and procedures were in place and management of abuse is included in staff induction. Discussion with a relative and a visiting social worker demonstrated that they were satisfied with the care delivered and had no major concerns. The Manor Nursing and Residential Home DS0000001919.V296791.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.26 Quality in this area is adequate. This judgement has been made using available evidence including a visit to the service. Residents live in a safe and well-maintained environment. Comfort would be improved by further decoration and consideration given to the appropriateness of the floor coverings. EVIDENCE: A tour of the accommodation occupied by the person’s case tracked took place and communal rooms associated with them. This was undertaken with the owner. Overall the home was found to be clean and tidy. Two of the persons tracked were accommodated in the newest part of the home and the others were on the old building, it was evident that the rooms in the newer part of the building were better maintained and decorated. Rooms in the older part of the building were noticeably darker. One room tracked smelly strongly of urine and slightly damp. The owner stated that this was due to a problem with constant shampooing due to incontinence. The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 19 Discussion with the owner took place about the appropriateness of carpeting for the individual concerned and recommendations were made to consider the use of an alternative floor covering and to seek advice from a dementia specialist supplier. During this inspection it was noted that although accessible from the inside doors were locked during the day, the explanation given was that this was for security purpose and hygiene. No evidence was found in care plans to detail the agreement to this arrangement. It was recommended consultation with residents (where possible) and relatives takes place and supporting documentation is put in place in care plans to demonstrate agreement. No residents were able to confirm their agreement to this process. Observation of the bathing and toileting facilitates provided demonstrated that those persons tracked had a choice whether they bathed or showered. Observation of the lounge/dining room and corridors in the older building demonstrated that radiator guards had not been fitted as per previous requirements made in past inspections. Discussion with the owner and maintenance person took place regarding the safety of residents and preventing burns and scalds. It was recommended that radiator guards are put in place as soon as reasonably practicable and that appropriate priority is given to the areas where residents might be more at risk. It was further recommended that risk assessments were put in place to address individual risks until this work is completed. Discussion took place with staff about maintaining levels of cleanliness and it was apparent by discussion and looking at staff rosters that there were two cleaners on duty most days and occasionally three. It was indicated that cleaners were also responsible for maintaining the laundry. It is recommended that a review of the ancillary staff be undertaken. The Manor Nursing and Residential Home DS0000001919.V296791.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27.28.29.30 Quality in this area is adequate. This judgement has been made using available evidence including a visit to the service. Recruitment and training is improving however residents are not fully protected due to lack of attention given to obtaining and updating of police checks before employment. EVIDENCE: Staff rosters were seen and included ancillary staff. The acting manager stated that as per the recommendation made at the last inspection staff now rotate between both sides of the home to ensure they are familiar with all residents needs. Additionally changes have been made to deployment of staff and the acting manager said that it has been agreed that to meet the needs of early risers that 1-2 staff come in earlier to assist night staff with the getting up process. Roster seen indicate that there are always one registered nurse and four care assistants on duty in the morning and three care assistants and one registered nurse in the afternoon. Night staff includes one registered nurse and three care assistants. The use of agency staff has decreased in recent weeks and since the acting manager’s appointment. None of the staff currently employed have a specialist qualification such as mental ill health. It was recommended that this be considered when appointing new staff. The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 21 Discussion with the acting manager took place about the level of afternoon staff and it was stated that she considered this to be appropriate but would monitor. Further discussion with the acting manager indicated that a number of staff have recently left the homes employment but that these posts have now been filled with new staff. Several overseas staff who are qualified nurses are currently working as care assistants and the manager and inspector discussed how they might retain their clinical skills. The acting manager stated that she intended to provide them with medication training to enable them to administer to residential residents. None of the residents tracked were able to make comments about staff or the impact that changes had on them, however reviews of care and discussion with a relative and social worker indicated that they were satisfied with care provided. Staff were observed at work and although many were from other countries were pleasant and friendly and approached residents in a sensitive and appropriate manner. A relative said my XXXXX has “never been happier whilst living in the home” Four staff files were inspected and most contained the required information. However concerns had been raised previously about recruitment practises in the home and with the previous manager however evidence seen in staff files indicated that this was improving. The information provided by the owner of the home indicated that a number of staff did not have a current CRB disclosure (police check) this was explored with the owner and acting manager and supporting evidence was supplied indicating that many were either staff employed from abroad (who had not supplied copies of their police checks from their country of origin) or who had not been received back from the disclosure department in a reasonable timeframe. Staff files seen indicated that they had been applied for; some CRB checks were out of date and required renewing. Evidence was seen of a new induction programme, which the acting manager was commencing, and also internal and external training. The owner had invested in a number of training videos, which he uses to train staff internally. Discussions with the owner took place about the type of training which might be required and included specialist training including dementia care mapping, and management of difficult or challenging behaviours. The Manor Nursing and Residential Home DS0000001919.V296791.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.33.35.38 Quality in this area is adequate. This judgement has been made using available evidence including a visit to the service. The health welfare and safety of residents is protected by policies and systems in place. Changes in management have improved the culture of the home and indicates that rights and best interests are being considered. EVIDENCE: The person currently in charge of the home is an acting manager who is a qualified nurse. It was not established if the acting manager has the registered managers award. The acting manager is supported by the owner and his wife who are also registered nurses and both of whom work in the home each day. The acting manager has applied to the Commission for Social Care Inspection to be registered. Information provided indicated that approximately 55 of staff currently have the NVQ (national vocational qualification) The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 23 Discussion with the acting manager and the owners indicated that good relationships exist between them and there was evidence of a supportive organisational structure. The acting manager stated that she has been supported in her decision-making and the changes she has made. She stated that she intended to spend more time observing and monitoring clinical and care practice in order to improve quality further. Evidence was provided of improvements to quality assurance monitoring, this included more frequent audits of care plans, increased supervision of staff and the development of a relatives questionnaire which was due to be sent out. Discussion with staff and written evidence seen demonstrated that a key worker system has been put in place and was working effectively. Evidence provided and case tracking evidence demonstrated that the home are not responsible for resident’s money and that appropriate persons manage this aspect of need. Information supplied by the owner regarding all routine maintenance and service checks indicated that all was up to date. The current insurance certificate was seen and is valid and appropriate. Most risk assessments observed in care plans addressing needs were recently updated. However one relating to residents tracked was significantly out of date. More general risk assessments relating to the environment were addressed in section 19-26 of this report. Evidence was seen where two persons who had left the building unknown were discussed with the acting manager and a discussion took place about the appropriateness of the lock on the front door. A social workers assessment had identified the need for a keypad type lock to be in place. The owner is recommended to consider the appropriateness of the current lock in relation to the categories of care registered for and also in relation to assessed /identified needs, including safety. An incident which has occurred in the home had not been reported to the Commission for Social Care Inspection as required in the regulations, further discussion with the owner indicated that they were not fully aware of their responsibilities and the type of incidents which should be reported. It was recommended that the owner read information provided by the commission on their website. The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 25 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. 2. Standard OP38 OP29 Regulation 37 19(4). (5) Sch2 Requirement All incidents affecting the health and welfare of residents must be reported without delay. The employer must ensure all staff have the necessary checks and support documentation as identified in schedule 2 of the Care Homes Regulations. Timescale for action 30/05/06 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The care plans whilst containing expected information are still in some cases separated into two documents which could be amalgamated to be more easy to use and to present a day to day working document. Risk assessments and care plans should be updated at least monthly and should be reflective of the current situation to ensure that safety and welfare is protected. 2. OP7 The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 26 3. 4. 5 OP29 OP9 OP30 6 7 OP27 OP38 The owner should ensure that all police checks of staff are documented on staff files and available for inspection. This includes staff appointed from other countries. The outcomes for residents might be improved if medication reviews were sought sooner where applicable. The owner should consider providing dementia care mapping training to the manager in order to ensure that training can be cascaded to staff in the management of repetitive behaviours. The owner should consider the recruitment of staff with mental health experience. Staff should be made fully aware of their responsibility regarding the reporting of incidents which occur in the home affecting residents. The Manor Nursing and Residential Home DS0000001919.V296791.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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