Inspection on 30/05/07 for The Manor Nursing and Residential Home

This inspection was carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

Other inspections for this house

The Manor Nursing and... 28/09/07

The Manor Nursing and... 30/05/06

The Manor Nursing and... 16/11/05

The Manor Nursing and... 23/08/05

The Manor Nursing and... 10/05/05

The Manor Nursing and... 17/11/04

The Manor Nursing and... 03/06/04

The Manor Nursing and... 11/03/04

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

CARE HOMES FOR OLDER PEOPLE The Manor Nursing and Residential Home 78-80 Lutterworth Road Aylestone Leicester Leicestershire LE2 8PG Lead Inspector Lesley Allison-White Key Unannounced Inspection 30th May 2007 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.V338550.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.V338550.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 themanorcarehome@hotmail.com themanorcarehome@hotmail.com Mr Bassir Jugon 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) ** 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.V338550.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person may be admitted to The Manor Nursing and Residential Home who fall 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 Manor Nursing and Residential Home No one falling within category OP may be admitted into The Manor Nursing and Residential Home where there are 49 persons of category OP already accommodated within the home The maximum number of persons to be accommodated at The Manor Nursing and Residential Home is 49 30th May 2006 2. 3. 4. 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. Fees range from £280.00 to £1,000 per week. The Statement of Purpose and Service User Guide (information about the service provided) are readily available and were frequently seen in residents’ bedrooms. The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 5 The Employers Liability Certificate of insurance is clearly displayed in the entrance hallway. Also seen was Registration Certificate from the Commission of Social Care Inspection (CSCI) and a copy of the last inspection report is available on request. The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is on outcomes for residents and their views of the service provided. On the day of inspection there were forty-eight residents however two residents were in hospital. The inspection took over seven hours to complete. Preparation included examining inspection records and information from the service history of the service. Other information was obtained from the CSCI pre-inspection questionnaires sent to residents, their families and to staff who work at the Manor. The Responsible Individual/Provider was also asked to complete a questionnaire about The Manor nursing and residential home. This aided the inspection process by providing background information. Discussion was held with two residents. The third resident was observed along with other residents during their daily routine. One of the residents was unable to communicate with the inspector the resident’s relatives spoke with the inspector at length. The primary method of inspection used was “case tracking”. This involved speaking with the residents who use the service provided, looking at three residents care plans and making observations. Four relatives spoke with the inspector and a number of other residents were observed during the day also. All the required key standards were inspected during this visit. Areas of concern raised by the last inspection report were discussed. New requirements were made at this inspection. The acting Registered Manager and deputy facilitated the inspection. What the service does well: The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 7 Residents’ comments included: When asked about her care X said that she has ‘no cause to complain and was very happy here.’ ‘ I am happy here they treat me well.’ ‘The staff at the Manor care home really tries to keep the residents happy and cheerful. They regularly have sing- songs, bingo and many other activities. They are also very caring and patient.’ ‘I can honestly say that at that at this present time I cannot think of any additional improvements required.’ Activities take place including time spent with staff on a one to one basis. A residents comment on the meals ‘I only like small amounts of food. The meals are very good.’ A relative’s comments on food ‘The food is always nicely served and very appetising and of a good variety.’ Residents are offfered choices wherever possible. One of the residents who spoke with the inspector stated that they did not take part in the activities but was happy to get regular meals and good care. ‘I would really like to say thank you to all the staff at the Manor from the managers to the domestics, they are all really appreciated.’ Relatives who spoke with the inspector felt that they were included in the care of their relative. Relatives comments included ‘Residents are treated with care and understanding and are given the respect that they all deserve.’ Food was seen that was pleasant and kept hot in a heated food trolley. Residents were assisted on a one to one basis and they did not appear to be rushed whilst they ate their meals. What has improved since the last inspection? Responsible Individual has now addressed this issue at number 78 as the door to the front of the building opens automatically, triggered by the fire alarm. On number 80 a key is being used to manually open the front door. The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 8 Some of the bedrooms had been recently refurbished with either new carpets or laminate flooring. The acting Registered Manager said that she would monitor the new laminate flooring for its practicality and cleanliness. 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 Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are given information about the home in order to make an informed decision about whether the service is right for them. EVIDENCE: Potential residents and /or their relatives receive a copy of the Service User Guide and Statement of Purpose giving them information about the Manor Nursing and Residential home. Relatives who spoke to the inspector said that when selecting the Manor they just turned up the acting Registered Manager welcomed them, they were shown around the home and made to feel welcome. Three service users were case tracked all three had pre-assessments in their care plans relating to their needs. Standard 6 Intermediate care is not offered at this care home. The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The health and care needs of individual residents are met. However, the administration and auditing of medications must be improved to ensure the safety of residents living at the Manor. EVIDENCE: Assessments in the care plans seen were up to date they included; Nutritional screening, mentlal health assessments, moving and handling information, and assessments for trips and falls. Staff who spoke to the inspector were able to describle the care needs of the residents. In this way the staff at the home were able to demonstrate part of their caring role. One of the residents case tracked had received an injury relating to hoisting this resident. CSCI were notified through the Regulation 37 procedure. (Care The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 12 homes are required by law to notify the Commission for Social Care Inspection of any incidents that adversley affect the well being of any resident). This resident was able to explain what happened and did not blame the staff for the injury sustained. The care record fully explained the incident and it was recorded in the accident book kept by the home. Accidents are reported and recorded in the accident book. This is good for the next staff member to follow and further supports the care provided. The inspector observed a transfer where the two carers used a hoist. The resident spoke to the inspector afterwards and said that they were happy with the care that they received at the Manor. Other residents were seen wandering around the home as they pleased in this way residents are encouraged to remain independent. In all three care records there was clear evidence of care planning and follow up treaments when needed. Residents who spoke with the inspector or had completed and returned the questionnaires felt their care needs were met, that they were treated with respect and their dignity maintained. Relatives also confirmed that they agreed that this was so. The management of medication is poor. The medication of four residents was checked and numerous instances of poor or unsafe practices were found, which have the potential to compromise the health and safety of residents. One medication was out of stock for 13 days with no evidence of having been followed up by the Registered Nurses. Medications were sometimes written by hand instead of asking the Pharmacist to send a typed label to avoid the possiblity of errors due to poor handwriting. When medications were received they were not always signed in, checked for amount or dated. One medication was changed, written by hand and ‘other’ written in its place. There was no explanation given on the back of the medicine recording sheet as to why the change was necessary. There were no photgraphs of residents in either the care plans or the medicine records which would help new staff to identify residents easily. Controlled drugs were checked and were satisfactory. Relatives comments included ‘They keep the residents clean and tidy, the staff are very friendly and polite.’ ‘My parent has only been in the Manor for a short while, we had problems getting my parent to settle in. The staff at the home have been brilliant. Their The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 13 patience and care has been great. The Manor definitely meets the needs of my parent.’ ‘I make regular telephone calls to the Manor so that I can keep in touch with how my relative has been . The staff always give me a full acount of how my relative has been, how they have eaten and how they are at that particular moment.’ ‘The Manor always gives my parent the support that we expect.’ The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are invited to take part in activities within the home that they enjoy. However, care plans should also reflect their identified social needs. In this way residents can benefit from continued help from different members of staff. EVIDENCE: There was no clear evidence of activity plans in any of the care plans seen by the inspector although activities take place including time spent with staff on a one to one basis. ‘ I like a game of dominoes but I cannot join in everything. I get to speak to the activities coordinator a lot though’. ‘I like bingo which is once or twice a week’. Families who spoke with the inspector felt that they were included in the care of their relative. The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 15 Residents are offfered choices wherever possible. One of the residents who spoke with the inspector stated that they did not take part in the activities but was happy to get regular meals and good care. Relatives comments included ‘Residents are treated with care and understanding and are given the respect that they all deserve.’ Food was seen that was pleasant and kept hot in a heated food trolley. Residents were assisted on a one to one basis and they did not appear to be rushed whilst they ate their meals. A residents comment on the meals ‘I only like small amounts of food. The meals are very good.’ A relative’s comments on food ‘The food is always nicely served and very appetising and of a good variety.’ The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Provider has procedures in place for dealing with complaints and protection. In this way residents are protected from harm. EVIDENCE: The Commission of Social Care Inspection (CSCI) has received complaints about the Manor Nursing and Residential Home since the last inspection. The complaints were checked. There was good evidence of the acting Registered Manager fully investigating any complaints and the reply given to the person making the complaint. Residents and relatives who spoke with the inspector were able to explain that they knew who to go to if they had a concern or complaint about the service provided. The acting Registered Manager was able to show the inspector the staff training records. Staff receives training on the Protection of Vulnerable Adults (POVA). The inspector spoke with three staff members. They were aware of the procedures in place to protect the needs of the residents in their care and The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 17 could explain the care needs for individual residents. In this way residents are protected. The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with a comfortable environment however regular checks should be made to ensure that the environment is also kept safe at all times. EVIDENCE: The home was tidy. Bedrooms seen by the inspector were clean and tidy. Shared bedrooms had ceiling curtains so that the residents could maintain their privacy when receiving personal care. Bedrooms that the inspector saw had wall racks they were used to hold the Service User Guide. This would act as a reminder for anyone who may need to check details about the Manor care home. The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 19 Two cleaning staff were on duty on the day of inspection. The inspector was shown the rota and it indicated that three members of staff were normally employed. The acting Registered Manager explained that due to personal reasons the domestic staff rota was currently short however this would be addressed very soon. Some of the bedrooms had been recently refurbished with either new carpets or laminate flooring. The acting Registered Manager said that she would monitor the new laminate flooring for its practicality and cleanliness. It was noticed that the rug at number 78 in the hallway was torn and ruffled on one side. It is a potential tripping hazard. Lights in downstairs hallway were checked and worked. Relatives’ comments included: ‘The Manor is spacious, it is very good for residents who are able to get about.’ The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Specialist training for staff is needed. Discussions should take place with residents about the issues around culture and diversity within the Manor. It could involve both residents and staff. EVIDENCE: The last inspection report made recommendations some of which have been completed. New Registered Nurses have been recruited which includes specialists in the part of the register for mental health. Previously, staff members did not have this important qualification to adequately meet the needs of the residents living at the Manor nursing and care home. One of the residents had regular episodes of difficult behaviour; the management team at the Manor has attempted to address this by buying in agency staff. They provide one to one care for this resident with difficult behaviour. However as a long-term prospect this could prove expensive and this does not address the issue of training for regular care staff as they may not have benefited through learning techniques, how to handle residents who display challenging or difficult behaviour requiring specific care and observations. There are other residents with difficult behaviour who also live at the Manor. The acting Registered Manager explained that further support for The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 21 the staff is in progress as the acting Registered Manager is seeking help from other organisations to provide specialist training including dementia care, and the management of difficult or challenging behaviours for the staff at the Manor. Evidence of other staff training is provided in basic areas of health and safety or care. Residents’ comments included: ‘ We’ve got people who do not speak or understand English. There are a lot of foreigners who do not understand us.’ This would suggest the need for discussion about the issues of diversity in the work force and within the home. It also suggests that this has not been addressed for some of the residents who may feel this way. ‘The staff are good but I do not always agree with them.’ ‘I do not always know who to speak to and if I did would I get any answers?’ ‘Staff usually come to me when they can.’ The new acting Registered Manager has not been registered with the Commission therefore information about the manager is to be sent by the Responsible Individual to ensure that correct recruitment practices have been maintained at all levels. This has now been done. The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Responsible Individual should ensure that safe working practices are in place and records are provided at the home in this way residents are protected at all times. EVIDENCE: During the last 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 purposes. The acting Registered Manager explained that the Responsible Individual has now addressed this issue at number 78 as the door The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 23 to the front of the building opens automatically, triggered by the fire alarm on number 80 a key can be used to manually open the front door. Visitors who spoke with the inspector were aware of the need to sign in and out of the visitors’ book in the case of an emergency such as fire where they would need to be accounted for. Staff records show that the staff has received training in the area of health and safety. In the older part of the building the radiator covers have not all been completed. This was mentioned in the last report. The Responsible Individual will be asked to produce a copy of the generic risk assessment for this part of the building to ensure that the overall safety of residents against the risk of scalds and burns has been taken into account. A requirement has been made for this. The Manor has a programme of replacement and redecorating within the home to ensure that the homely environment is maintained. The Registered Provider does not hold money for residents. The families or appointed persons are appointed to do this. Notifications of events, which affect residents, such as falls, are now reported to the Commission for Social Care Inspection, who will monitor this information. A maintenance person ensures that checks and repairs are routinely carried out and that health and safety issues are reported. Relatives who completed the questionnaires sent by CSCI or who spoke with the inspector felt that they were involved in the care of their relative when appropriate. ‘The staff at the Manor care home really tries to keep the residents happy and cheerful. They regularly have sing songs, bingo and many other activities. They are also very caring and patient.’ ‘I can honestly say that at that at this present time I cannot think of any additional improvements required.’ ‘I would really like to say thank you to all the staff at the Manor from the managers to the domestics, they are all really appreciated.’ The Manor Nursing and Residential Home DS0000001919.V338550.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 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 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.V338550.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement Improvements must be made in the ordering and supplying of medications and all Registered Nurses should see this as part of their duty of care to ensure that residents do not go for long periods of time without their perscribed medications. Changes to medications must clearly indicate the reason for the change and authorisation in order to avoid the possibility of mistakes being made. Handwritten MAR sheets must be complete and accurate and written by trained and competent staff and whereever possible witnessed by a second trained and competent member staff. In this way hand writing errors can be avoided. A Social activity plan must be provided for each resident so that all staff can have access to and use it to enhance the quality time spent with residents. To monitor the environment for the safety and well being of DS0000001919.V338550.R01.S.doc Timescale for action 31/08/07 2. OP9 13 (2) 31/08/07 3. OP9 13 (2) 31/08/07 4. OP12 14 30/09/07 6. OP19 23 (2) © 31/08/07 The Manor Nursing and Residential Home Version 5.2 Page 26 staff, residents and visitors. 7. OP22 23 (n) In the older part of the building the radiator covers have not all been completed. This was mentioned in the last report. The Responsible Individual is now asked to produce a copy of the generic risk assessment for this part of the building to ensure that the overall safety of residents against the risk of scalds and burns has been taken into account. 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP27 OP30 Good Practice Recommendations Discussions should be held with residents and staff who live or work at the Manor to ensure that issues around cultural and diversity are shared. 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 challenging behaviours. The Manor Nursing and Residential Home DS0000001919.V338550.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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