Inspection on 06/09/05 for The Manor Nursing Home [Bishop`s Hull]

This inspection was carried out on 6th September 2005.

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

Other inspections for this house

The Manor Nursing Home [Bishop`s... 05/11/08

The Manor Nursing Home [Bishop`s... 15/08/07

The Manor Nursing Home [Bishop`s... 14/06/06

The Manor Nursing Home [Bishop`s... 13/03/06

The Manor Nursing Home [Bishop`s... 03/02/05

The Manor Nursing Home [Bishop`s... 25/05/04

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE The Manor Nursing Home Haydon Close Bishops Hull Taunton TA1 5HS Lead Inspector Stephen Spratling Unannounced 6 September 2005 th 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 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 and 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 Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Manor Nursing Home Address Haydon Close, Bishops Hull, Taunton, Somerset, TA1 5HS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01823 336633 Barchester Healthcare Homes Limited Care Home 86 Category(ies) of OP Old Age [86] registration, with number PD Physical Disability [20] of places The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1.Elderly persons of either sex, not less than 60 years, who require general nursing care 2. Twenty-one places for persons of either sex, in the age range of 20-59 years, who require general nursing care, to include one named service user, as detailed in the letter dated 20th December 2004. To reduce to twenty places when a younger adult is discharged. 3. Up to three places for personal care. 4. Registered for a total of 86 places in categories OP and PD. Date of last inspection 3 February 2005 Brief Description of the Service: The Manor Nursing Home is registered to provide care for a total of 86 people, most of whom must be over 60 years of age but up to 21 of whom can be aged between 20 and 59 years of age. The home was purpose built and is set in attractive landscaped gardens with ample car parking space. Accommodation is mainly provided in single bedrooms all of which have en-suite facilities. The home has a variety of specialist equipment to meet of needs people with physical disabilities. Corridors are wide and equiped with handrails. There are a variety of communal areas which are comfortably furnished; one lounge is set aside for the use of younger residents. Residents are free to spend time where they wish and with whom they wish; visitors are welcome at the home without appointment. The home employs registered nurses, carers, activites staff, catering and housekeeping staff to care for residents and provides them with the services they need. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and conducted by two inspectors, Stephen Spratling and Susan Lyons. The inspection started at 9.45 am and ended at 4.45 pm. During the inspection the inspectors spoke with the home manager and deputy manager, one of the registered nurses and six of the care staff on duty. They also met and spoke with 15 of the residents; one inspector ate lunch with residents in the dining room. The inspectors met one visitor on the day of the inspection and have spoken with one regular visitor to the home since the inspection. The care records of eight residents were looked at. What the service does well: What has improved since the last inspection? What they could do better: Residents need to be invited to have more say in deciding how their care is to be delivered. Some of the younger people at the home would like access to more activities. Systems for managing medication are better but further work is needed to ensure that procedures are followed on every occasion. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 6 The home needs to ensure that residents receive prompt care on all occasions and that all staff communicate clearly with residents. The home must make sure that any allegation of abuse are properly reported and acted upon. 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 Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed during this inspection. This home does not offer and intermediate care service. EVIDENCE: The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Care planning helps to ensure that residents physical needs are met but they do need to be improved to ensure that they clearly reflect individual residents personal preferences and to take fuller account of residents social care needs. Systems for managing and recording the administration of medication have improved since the last inspection but failure to follow these procedures on every occasion means residents are at some risk from errors. Resident’s benefit from having their health care needs recognised and met. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 10 Residents receive prompt care and feel treated with respect the vast majority of the time, however work is needed to ensure that this happens without exception. EVIDENCE: Eight care plans were sampled. They all contained good detail of how resident’s physical needs are to be met but there was generally very little information concerning the social needs of the individual residents. They were dated to show that they are being reviewed either monthly or two monthly. Some residents confirmed that their care plans were discussed with them but others were unsure or said they had not. Residents asked did not have copies of their care plans; the manager reports that residents can have access to their care plans at any time on request. It was not possible to see from the plans themselves as to whether they had been discussed with the resident; residents or their representatives had not signed them. The inspectors looked at the medication storage and management on the 1st floor. They saw that all medicines were securely stored; medication administration charts were mostly properly completed though some gaps were seen meaning it was not clear if medicines had been administered or not; several medications expiry dates were checked and all were within the use by date; the medication fridge temperatures were being monitored but it was not clear what action was taken when temperatures exceeded the recommended limits as had happened on a couple of occasions in the previous month; charts showed evidence that medications received in the home are signed for; hand written charts were properly signed; when medication is given in an altered form e.g. crushed to go down a feeding tube, it was not clearly recorded why this was being done or what checks had been made to ensure that the effect of the drug was not changed by crushing. The manager described clear systems for medication management , reporting that each registered nurse is assessed in medication management annually, but acknowledged that further work is needed to ensure procedures are followed on every occasion. Staff were seen to knock on resident’s doors before entering on most occasions but not all and residents confirmed that their mail was given to them unopened. Twelve of fifteen residents spoken with said that staff are polite and kind, one resident commented “they are all very nice”. Three of fifteen residents said that most staff were nice but some are not always polite, one of these people said they find “one or two staff are impatient”. The manager said he believes that these concerns are likely to be related to cultural differences of some overseas staff who are currently being supported to improve their communication with residents. A visitor to the home expressed concern that the person they were visiting had on one occasion been incontinent and had to wait 30 minutes before staff had The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 11 time to change them. Some residents said that they get help in good time when needed; others said that sometimes they have to wait too long for help, one person said they often have to wait up to 20 minutes when on the commode before staff come back to help them off. Hoists and technical aids are available although one resident was without his wheelchair as it was being repaired. Staff were aware of this and said they would see if it could be hurried up. Residents were seen choosing to spend time with others and some spending time alone in their rooms. A resident confirmed that the GP calls each week at the home and that when he was feeling unwell he had been asked if he wanted the GP called. Consultations with community health care professionals such as continence specialist nurses and community psychiatric nurses were seen in resident files. Residents healthcare needs were seen clearly recorded on the individual care plans. Staff reported that they have the equipment they need to care for residents properly. A variety of pressure relieving equipment was seen in use around the home. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with asssistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Social activities are provided at the home and provide daily variation and interest for most people, however further work is need to ensure the needs of all residents are recognised and met. Residents benefit from being supported to spend time where and with whom they choose, and from the contact with family and friends, which is encouraged by the home. A varied balanced diet is provided, served in a pleasant atmosphere, with individual support given discreetly as needed. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 13 EVIDENCE: Activity staff do take residents out on an individual basis but generally residents go out into the community with relatives. Two of the younger residents told the inspectors they would like more to do, the care plans of these two people did not give detail of the activities they would like help to be involved in (see standard OP 7/ YA 6). All other residents asked indicated they are happy with the activities available. Several of the older residents spoke highly about the activities staff one person describing them as “worth their weight in gold” another saying the coordinator is “excellent”. One resident said that they go out most Mondays and have had opportunity to try several activities for the first time since living at the home including pottery, going to the theatre and a flower show. Residents and a visitor confirmed that they are able to have visitors when they want and they can see them in their room if they wish, a communal area or the garden. Discussion with residents confirmed that they have unrestricted access to all the communal areas of the home and grounds. Residents confirmed that they are able to get up and go to bed when they wish. One resident said that at weekends he liked to stay in bed, this was seen documented in the care plan. Most residents said the meals were nice although some people said it varied. It was noted that a member of staff visited those people eating in their rooms to check what they wanted for their meal. One inspector sat with residents in the dining room at lunchtime. Residents sat around small tables together, were offered drinks (including wine) and a choice of meals. Staff sat patiently with residents who needed help to eat and chatted warmly with residents. Residents said the food was good. One resident said they feel the evening meal “lacked imagination”. The manager reported that the home chef meets residents on admission and is very happy to respond to requests. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Residents can be confident that their complaints will be taken seriously. Proper procedures are in place to guide staff if they are concerned a resident is being abused but failure to follow these procedures does mean residents can not be confident that appropriate action will be taken if they are being abused. EVIDENCE: A resident confirmed that he had been given a copy of the complaints procedure. Several residents said that the manager and deputy are approachable and that they act on complaints. Staff asked confirmed that they have received training in Adult Protection and they were aware of what to do if they saw a resident being treated inappropriately. The home has an adult protection policy. However an entry in the daily recording was seen where it appears an allegation of abuse has been made by a resident to staff but not reported to the manager and therefore no action had been taken. This was discussed with the manager on the day of the inspection who has provided evidence that the concern has now been addressed properly and was unsubstantiated. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 The home is safe, well maintained and kept clean, providing a comfortable homely environment for residents. EVIDENCE: All residents who were spoken with to were happy with their bedrooms all of which were ensuite. Evidence was seen that residents have been able to bring their own possessions into the home and to personalise their own room. Areas of the home seen were clean and well maintained. Anti bacterial hand washing gels were available around the home and a member of staff was seen to be using them. Details in relation to infection control were seen on individual The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 16 care plans and care staff confirmed they had received training to cover this. One visitor to the home told the inspector that they do not always think their friends room is properly cleaned everyone else spoken with said that they are happy with the standards of cleanliness. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 Staff are employed in sufficient numbers but residents are sometimes let down by the isolated failures of some staff to provide care promptly. Service users are protected by the robust recruitment procedures followed at the home. EVIDENCE: During the day of the inspection staff were seen working steadily and did not appear to be rushed. Staff who spoke with the inspectors said that there are usually enough of them on duty to provide care to residents in an unrushed manner. Most residents said they felt there are always enough staff on duty, three others gave examples of having to wait excessive time periods for help (see section on health and personal care) to support their view that there are sometimes not enough staff on duty. Most residents said staff usually respond to call bells quickly but some staff will cancel them saying they will return in a minute then can be 20 minutes or more before coming back. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 18 The recruitment paperwork for several staff was sampled and seen to contain all the required information. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s polies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 33, 35 and 38 (Older People) and Standards 23, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 38 Residents trust the manager to act in their best interest and benefit from the open accessible approach of the homes managers. Residents are protected from harm by good risk assessment and management practices. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 20 EVIDENCE: One of the residents said that the new manager visits everyone each week to see if they are all right and he has said his door is always open for people to discuss things with him. Two visitors and several residents commented that find the manager and deputy very approachable. Staff also said that managers at the home are supportive. Through out the inspection the manager and deputy were knowledgeable about the service and helpful to the inspectors. The commission is currently processing the managers application to be formally registered. Staff confirmed that they receive fire safety training every month. Risk assessments were seen on individual care plans. Generally the ones seen were about moving and handling, wheelchairs and infection control and provided adequate information. Risk assessments, as previously recommended, for the use of bed rails were not found by inspectors in residents records on the day of the inspection; since the inspection the manager has provided evidence that they were and are being completed properly. This will be re-examined at the next inspection. The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 3 x 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 3 x x x x x x 3 Score Standard No 7 8 9 10 11 Score 1 3 1 2 x Standard No 27 28 29 30 2 x 3 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x 1 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 x 33 x 34 x 35 x 36 x 37 x 38 3 The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 22 yes 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 OP 18/YA23 Regulation 13 (6) Requirement The registered person must make arrangements.. to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. (all allogations must be treated seriously and responded to according to adult protection procedures) Unless it is impracticle to carry out such consultation, the registered person must after consultation with the service user, or a representative of his, prepare a written plan (the service users plan) as to how the service users needs in repsect of his health and welfare are to be met. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (The home must ensure that a record is made of the administration or refusal/nonadministration of medicines to all service users. The home must ensure that all medicines are stored at the required Timescale for action 6-10-05 2. YA 6/ OP 7 15 3. YA 20 OP 9 13 (2) Previous requiermen t timescale not met. New timescale to be completed by 31/12/05 Previous requiermen t partially met. New timescale 31/12/05 The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 23 temperature.) 4. 5. 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 YA6/OP 7 Good Practice Recommendations Care plans should set out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. All staff should treat service users with respect at all times. The home should ensure that the staff team work effectively at all times to meet all the needs of service users. 2. 3. 4. 5. OP 10 YA 33/ OP27 The Manor Nursing Home D54-D06 S3300 ManorNursingHome V248362 060905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Suite 1, Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. 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