Inspection on 16/07/07 for The Manse

This inspection was carried out on 16th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 Manse 02/02/06

The Manse 21/01/06

The Manse 21/06/05

The Manse 16/11/04

The Manse 14/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Manse Cargoll Road St Newlyn East Newquay Cornwall TR8 5LB Lead Inspector Ian Wright Unannounced Inspection 9:30 16th and 18th July 2007 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 Manse DS0000046439.V340496.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 Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manse Address Cargoll Road St Newlyn East Newquay Cornwall TR8 5LB 01872 510844 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) Louise@themanse15.wanadoo.co.uk Underhill Care Ltd Mrs Philippa Louise Jewell Care Home 23 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (23) of places The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th March 2007 Brief Description of the Service: The Manse provides care for up to 23 elderly residents. This includes up to 16 people who may have dementia. The home is in the village of St. Newlyn East, which is situated between Truro and Newquay. The Manse has 21 bedrooms of which 19 are single bedrooms. All bedrooms have an en-suite toilet and washbasin facilities. The home has a garden and parking for visitors. There are two shared lounges and a dining room. The home is well maintained with good quality furnishings. Respite care is offered. Some day care for up is also provided. A copy of the inspection report is available in the hallway, and it is suggested a copy is requested from management if required. The range of fees at the time of the inspection is £300 to £370 per week. There are additional charges e.g. for hairdressing, chiropody, and newspapers etc. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Key Inspection took place over ten and half hours over two days. All of the Key Standards were inspected. The methodology used for this inspection was: • To case track six people who use the service. This included, where possible, interviewing the people who use the service about their experiences, and inspecting their records. • Interviewing three staff about their experiences working in the home. • Informal discussion with other people who use the service and staff. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: This inspection has resulted in six statutory requirements. The registered persons are required to take appropriate action as required by law and within the timescales set. In brief: • The review of care plans needs to be more detailed. There needs to be a comprehensive manual handling risk assessment for each person living in the home, which is regularly reviewed. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 6 • • • • • Any allegations of abuse must always be reported to the Department of Adult Social Care (Social Services) at the lead agency for any investigations. Staffing levels must always be maintained to agreed levels with CSCI. Where there are staff shortages agency or bank staff should be employed. Inexperienced staff should not be left in charge of the home. All staff must have a Protection of Vulnerable Adults check (POVA First) before they commence employment. A suitable quality assurance system still needs to be in place-as previously notified at the last key inspection. Some health and safety precautions need improvement- as outlined in the main text. 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 Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 7 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 Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 8 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): 2, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered persons have developed a contract / statement of terms and conditions of residency. These documents have been issued to people who use the service. The provision of suitable information ensures people who use the service are aware of the services the registered persons offer. This information also helps ensure people who use the service are made aware of their rights and responsibilities. The registered persons have a suitable assessment procedure. There is suitable evidence that people who use the service have been assessed appropriately before admission is arranged. Suitable assessment procedures should ensure the home only accommodates people for whom the registered persons can suitably meet their needs. EVIDENCE: Files for people who live in the home were inspected. Each person has a copy of the home’s statement of terms and conditions of residency / contract. A The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 9 copy of a contract issued by the Department of Adult Social Care (social services) is also on file where this is applicable. The registered manager said the people who use the service have a copy of this documentation. The registered persons have a suitable assessment policy. There is satisfactory evidence that a senior member of staff has assessed the people who use the service, before admission was arranged (for example copies of pre admission assessments were available for inspection). Some of the people who use the service, who the inspector could speak to, remembered a senior member of staff completing an assessment before they moved to the home. Some people who use the service said they were able to visit the home before moving in, and others said a relative visited on their behalf. In some cases a copy of a social services / health assessment has been obtained by the registered persons. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is generally good, although some improvement is required to care planning processes. This judgement has been made using available evidence including a visit to this service. People who use the service have a care plan. However some improvement is required to ensure all care plans are reviewed more thoroughly, and all people who use the service have an up to date manual handling assessment. Suitable care plans help to ensure people who use the service receive all the care they need, for example, in a consistent manner. The medication system is managed to a satisfactory standard so people who live in the home can be assured their medication is looked after and administered appropriately. People who use the service said they felt staff worked with them in a manner, which respected their privacy and dignity. This was also evident from the inspectors’ observations. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 11 EVIDENCE: Care plans for some people who use the service were inspected. These appeared to be satisfactory, and contained adequate information to assist staff to provide care. However care plans need to have an up to date manual handling assessment so staff are fully aware what support and aids people need when they need assistance in this area. Care plans appear to be reviewed, but there needs to be more detail regarding any changes that occur in peoples’ needs and abilities. Currently staff are only writing ‘no change’. However, for example one person’s care plan said they did not need assistance with manual handling, but the inspector observed the person having assistance from staff in this area. Some care plans have a history of the person, for example, whether they had family, their hobbies and / or what job they did etc. This should be completed for each person to give staff a holistic picture of the person’s life. One person’s care plan was incomplete and this needs to be finalised. Some people who use the service did not appear to be aware of their care plans. However everyone the inspector spoke to say the care they received was appropriate, and carried out in a manner according to their wishes and needs. Health care support appears to be satisfactory. People who use the service said they could see a doctor or other medical practitioner when this is necessary. There are suitable records regarding any medical interventions received from medical professionals. The inspector spoke to a district nurse and a community psychiatric nurse who both said care received by people living in the home is to a good standard. The medication system was inspected. Medication is stored in individual locked cupboards in residents’ bedrooms. Medication is administered via a monitored dosage system. The operation of the system is to a good standard. For example medication sheets are signed appropriately, and there was no excess stock. However medication to be returned for disposal is building up and needs to be returned to the pharmacist. This should be entered into the returns book when it is highlighted for return, rather than recorded just before it is returned. This will ensure there is more accountability regarding stock to be returned. Staff who administer medication appear to have received suitable training from a pharmacist. People who use the service spoke positively regarding the attitude of staff, and said staff respected their privacy and dignity. This was also evident from the inspector’s observations. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Routines and arrangements for activities are satisfactory so people who use the service can live a suitable lifestyle. Visiting arrangements are flexible. Arrangements to assist people who use the service with their finances are satisfactory. Meals are provided to a good standard, so people who use the service can receive a wholesome and nutritious diet. EVIDENCE: Most people who use the service said they could get up and go to bed when they wished. However, one person said they would like to have their breakfast later than 7:30 when it is usually served. This will enable people living in the home to get up at different times if they wish. When this was discussed with the manager, she said people living in the home could have their breakfast later if requested. It is recommended staff survey people living in the home to ascertain what time they would like their breakfast. This should also be asked when people move into the home, and perhaps reviewed on a six monthly basis. However, the morning routine was relaxed and there did appear to be a lot of flexibility when people got up. People were not got up ‘en masse’, or all sitting in the lounge dressed by 9 or 10 am. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 13 People living in the home either spend the majority of their time in the lounge or in their bedrooms. There are some organised activities for example there is an organised keep fit session once a week. There are also bingo sessions, an entertainer visits every 6-8 weeks and occasional trips out. Some people who use the service go into the village or to the church on their own. Many people will go out with their relatives on a regular basis. Staff also organise beetle drives and play board games with residents. The library visits the home. People living in the home said they were happy with how they spent their time, and felt there were not too many restrictions. People who use the service said they could receive visitors when they wished. People who live in the home can either receive visitors in their bedrooms, in the lounge or in the dining room. The Church of England minister visits the home to give communion every 6-8 weeks. One person who lives in the home said she used to organise a Methodist minister to visit the home regularly. However there has been problems in ensuring this service occurs regularly. This is not the fault of the home, but it would be a good idea if a member of staff could take on the task of re-establishing contact with the chapel, and asking them to conduct regular visits-particularly for the more frail people who cannot get out now. The registered provider assists with the management of money for some people living in the home. Records kept are satisfactory. Otherwise people who live in the home either look after their own monies or these are managed by their relatives / legal representatives e.g. via power of attorney arrangements. People who live in the home said they were able to bring small items of furniture and their belongings when they moved in. People living in the home said they enjoyed the food provided. The main meal is provided at lunchtime, and a choice of a hot and cold evening tea is offered. Staff go around once a day to ask what people would like for tea and this is subsequently prepared. Suitable records of menus are maintained. Special diets (e.g. pureed meals) are provided as required. Although a choice of main meal is not provided, people who live in the home said staff were aware of preferences, and an alternative is provided where necessary. It would be a good idea of the menu for each day was displayed, for example in the upstairs and downstairs hallways. The inspector shared a meal with people who live in the home, and this was to a good standard. Support provided at the mealtime was good, and the meal was a sociable occasion. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered persons have suitable procedures regarding complaints and adult protection. The Commission for Social Care Inspection was not satisfied how an adult protection issue was dealt with but management appear to have learned from this. It is therefore hoped that in future people who use the service can be assured the registered persons procedures will protect them if they have concerns regarding bad practice. EVIDENCE: The registered persons have suitable written procedures regarding complaints and adult protection. Staff and people who use the service showed some awareness of the procedures, and were able to say whom they would approach if they had a complaint or were concerned about abuse. Most staff have attended adult protection training. The Commission for Social Care Inspection was concerned how the registered persons dealt with two adult protection issues. Both matters should have been reported to the Department of Adult Social Care (Social Services) as the lead agency to lead the investigation, but were not. Other agencies such as CSCI also need to be informed. When one of the matters was finally referred the Department of Adult Social Care, they proved ineffectual at dealing with it. The Commission has taken this matter up separately with the Department of Adult Social Care. The failure of The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 15 the matters to be appropriately resolved could have put people living in the home at risk. However, it appears the registered persons have learned from the experiences, new more rigorous procedures have been introduced and these should provide people living in the home with more protection in future. One of these matters is dealt with in more detail in the random inspection report dated 20th December 2006, which is available from the Commission. Most staff and people who live in the home said they had not witnessed any abusive practices. All staff have Criminal Record Bureau check. Two new staff did not have a Protection of Vulnerable Adults check, but these have been applied for. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 16 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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manse provides a pleasant, homely, clean and well-maintained environment for people to live and feel at home in. EVIDENCE: The building was inspected. The building appears to be well maintained, clean, pleasantly decorated and homely. All communal rooms are homely and comfortable. There is a pleasant lounge, a dining room on the ground floor, and a lounge / diner on the first floor. There is also a conservatory which some people have their meals in. There is a pleasant garden, which seems safe for people with dementia to use without being accompanied. Bedrooms are individualised and comfortable. A stair lift is provided to assist people to go upstairs. All decorations are maintained to a very high standard, The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 17 and are fresh, homely and pleasant. On arriving at the home on the first day of the inspection, the inspector felt stuck by the home being so fresh and clean. There is a walk in shower on the ground floor, which offers a good facility particularly for those who are frail or have a mobility problem. There are two bathrooms on the first floor. However one of the bathrooms is not used. This should be adapted and recommissioned when possible. Suitable kitchen and laundry facilities are provided. Cleaning staff are employed, and the home was very clean and hygienic at the time of inspection. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 18 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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing arrangements need some improvement to ensure there are always suitable numbers of staff on duty. Recruitment records are much improved. However there are still some gaps between compliance with the regulations and current practice. This needs improvement before people living in the home can have confidence they are in safe hands at all times. Staff training provision is generally to a good standard and much improved. However there are still some shortfalls in training received by staff. Until these are addressed, people living in the home cannot be assured staff receive appropriate training as required by regulation, and staff have suitable skills and knowledge to cater for their needs. Equal opportunities issues regarding recruitment and work practices seem satisfactory. EVIDENCE: On the day of the inspection rotas show three members of staff were on duty from 0730 to 2200. There were two waking night staff on duty from 2145 to 0730. The registered manager works in the home at least five days per week, and works at times with people living in the home to provide personal care. Auxiliary staff such as cooks, cleaners and maintenance staff are employed. People who live in the home spoke positively regarding the staff and registered manager and felt their care was provided to a good standard. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 19 A concern regarding the level and ability of current night staff was made to the Commission for Social Care Inspection. The anonymous complainant alleged at times there were not two night carers provided (i.e. there was only one ‘sleep in’ person and one waking night person), one of the staff could not speak English very well and had inadequate training to do carry out their responsibilities. The person also alleged that at times only two members of staff were on duty during the day when there should be three. This matter was investigated as part of the inspection. The inspector found that there had been some occasions when only one waking member of staff was provided, and there was one sleep in member of staff. At the last inspection this was the usual staffing level provided. The registered persons made the decision to increase staffing levels at night, following the change in registration to provide personal care and accommodation to more people with dementia. The registered manager said there had been problems recruiting satisfactory numbers of staff, but this had now been rectified. She said there had been some occasions when only one waking night and one sleep in member of staff had been provided. This was because she did not have the capacity to have two waking night staff on duty. The manager said there was always three staff on duty during the waking day 07:30- 22:00. The shortage of night staffing is recorded on the rota, and according to rotas it appears there are always three staff on duty during the waking day. However on some occasions, during the waking day, there have been two established staff members and one person who is on induction (For example on the afternoon of the first day of the inspection). This limits availability of staff to people living in the home, as the trainee member of staff needs to be shadowed, particularly if they have not received a satisfactory Criminal Records Bureau (CRB) disclosure. The registered persons must therefore always ensure there are suitable levels of staff available according to the levels of staffing agreed with the Commission for Social Care Inspection. Where necessary the registered provider needs to recruit additional staff and / or agency staff to ensure suitable staffing levels are maintained. Regarding the allegation of foreign staff not being able to communicate with people living in the home, the registered manager said the foreign members of staff could all speak satisfactory English. The inspector was unable to speak to the member of staff who allegedly only speaks broken English as the person was off duty. However the registered manager assured the inspector that the person does have satisfactory English, and there are no communication problems with people who live in the home. The inspector was able to speak to two other staff, who originate from other countries, and both spoke satisfactory English. The majority of people who live in the home spoke The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 20 positively regarding the foreign workers, although one person did say they felt the English of some of the staff was poor. If necessary, the foreign workers should be encouraged to take additional English classes. It is essential that staff can communicate appropriately with people living in care homes, and this is especially the case with people who have dementia. The file of the member of staff who was allegedly not fit to complete night shifts was inspected. There were satisfactory recruitment checks completed on the person. The person had a record that they had completed induction training, including awareness of fire procedures. The registered manager confirmed the induction had occurred. However the person did not have any evidence of completing further training required by regulation such as first aid, and moving and handling training. It is essential that night carers have this training so they can be responsible for the care of all residents and have the necessary skills to carry out their duties. The person only started working at the home in May 2007, and the manager was able to provide evidence that the required training had now been arranged. The registered persons must ensure there is always suitably qualified, experienced and competent staff on duty at all times. If they are not able to do so from the existing staff complement, additional staff or agency staff must be employed. It is not appropriate for inexperienced staff to complete shiftsparticularly unsupervised. As a consequence people living in the home could have been put at risk. The registered providers have a suitable approach to providing National Vocational Qualifications (NVQ) for care staff. Currently 33 of staff have at least an NVQ 2. Four staff are in the process of completing an NVQ 2 and some staff that have an NVQ 2 are now completing an NVQ 3. Staff training required by regulation is generally to a good standard. Since the last inspection, the registered persons have made considerable progress to ensure the staff employed have suitable training required by regulation. This includes fire training, moving and handling training, infection control training, food handling training, health and safety training and first aid training. Most staff have also completed basic training regarding dementia. Where training in these areas has not been completed there appears to be clear plans to ensure the training is completed in the next few months. However situations, as outlined above regarding poorly trained night staff, must be avoided. Recruitment records were inspected. These are generally to a good standard and have improved considerably since the last inspection. For example all staff have completed an application form, there is a copy of suitable references on file for all staff, there are suitable records of staff induction and most staff have received a Criminal Records Bureau (CRB) check. The registered provider’s approach to equal opportunities and anti discrimination is The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 21 satisfactory. Staff spoke positively about the manager’s approach, the culture of care in the home and training provided. However two staff, who had just commenced employment at the home (i.e. in the last week), were still awaiting their CRB disclosure. The manager said a Protection of Vulnerable Adults ‘First’ check had been applied for, for both staff, but this had not been received. Although this is plausible, these people are still rostered to be on duty. According to the regulations these staff should only be working with people living in the home, once their POVA First check has been received. They should then only work supervised until full CRB clearance has been received. The registered manager said the POVA First checks should be returned in the next few days. She said the staff had been rostered on duty so satisfactory staffing levels could be provided. She also said that due to delays in the Criminal Records Bureau processing the checks, it is often the case staff will go and get another job if they are kept waiting too long to commence employment. Again, as outlined above, if satisfactory checks have not been completed they should not commence their duties (although they could complete induction and training). If necessary agency staff should be employed to provide satisfactory staffing levels. The Manse DS0000046439.V340496.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, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered persons appear to be suitably experienced to manage the home. Quality assurance processes however need improvement so people who live in the home can be assured there are systems in place to ensure continuous improvement, and regulatory requirements are met. The registered providers approach to handling residents’ monies is satisfactory, so people who live in the home can be assured their financial interests are safeguarded, where the registered providers are involved in this area of their lives. The management of health and safety issues need some improvement so people who live in the home can be assured they live in a safe environment. EVIDENCE: The registered manager appears to be caring and knowledgeable regarding residents’ needs. The staff, the inspector spoke to, say the manager was good to work for and provided them with sufficient support to help them to do their The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 23 jobs. For example a supervision and appraisal system appears to be in place. People who live in the home, who the inspector was able to speak to, were very positive about the registered manager’s approach. Quality assurance processes however need improvement. For example their needs to be satisfactory systems in place to ensure regulatory requirements are met. A survey of stakeholder views and an annual development plan are two methods, which could be used to assist in meeting this standard. The registered persons also need to return to the Commission the Annual Quality Assurance Assessment (AQAA). This was required to be returned to the Commission 14/6/07. The registered manager said she had not received the documentation. During the inspection, the inspector arranged with the CSCI Ashburton office for the documentation to be sent to the registered manager. Other formal written notifications required by law (for example of deaths, or any events which affect the well-being of any person who lives in the home.) are sent to the Commission. The registered persons look after some monies on behalf of people who live in the home. Suitable records are maintained regarding these. The registered provider does not act as agent or appointee for any people living in the home. The registered provider has a health and safety policy. Records kept of checks required by regulation need some improvement. There are suitable records of the testing of fire alarms, gas and portable electrical appliances. However testing of the emergency lighting by staff has not occurred since April 2007, although an approved contractor did complete a test on this equipment in June 2007. Staff do need to check this equipment at the intervals recommended by the fire authority. Although the electrical hardwire test was completed in November 2005, the electrical contractor reported the results were unsatisfactory. It is not clear whether remedial action has been completed since this test. If necessary this work needs completing, the circuit retested and a new certificate issued. This needs to be forwarded to CSCI. Accident records are suitably maintained. Health and safety risk assessments are satisfactory. There are suitable risk assessments regarding fire and the prevention of Legionella. Some control measures regarding legionella are in place. However, for example, the testing of thermostatic valves, and (where necessary) the cleaning of showerheads needs to be recorded. There are some gaps in health and safety training as highlighted in the ‘Staffing’ section of the report. The Manse DS0000046439.V340496.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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15. Requirement The registered person shall, after consultation with the service user, or a representative of his, prepare a written plan (“the service user’s plan”) as to how the service user’s needs in respect of his health and welfare are to be met. Care plans need to: • Be kept under review and reviews fully documented. • Include a full manual handling assessment, which is regularly reviewed. The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. (For example, in future any allegation of abuse must be reported to the local authority, which as outlined in their guidance, in the first instance will act as the lead agency to investigate any allegations. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 26 Timescale for action 01/09/07 2. OP18 10(1) 12(1) 13 01/08/07 3. OP27 OP29 18, 19 4. OP29 18. 19 Other agencies such as CSCI and the police may need to be involved.) The registered person shall 01/08/07 ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. (For example: 1. Satisfactory levels of staffing must be provided as agreed with the CSCI, and as outlined in this inspection report. Where necessary agency staff must be employed. 2. Staff must have suitable training appropriate to the work they are to perform.) 01/08/07 The registered person shall not employ a person to work at the care home unless the person is fit to do so. Satisfactory checks must be completed on the person to ascertain this. (For example a Protection of Vulnerable Adults ‘First’ check and other checks as outlined in Schedule 2 of the Care Homes Regulations 2001). The registered person shall establish and maintain a system for evaluating the quality of the services provided at the care home. Timescale of 01/11/06 not met Second Notification The registered person shall ensure that all parts of the home to which service users have access, are so far as reasonably practicable, free from hazards to their safety. Any unnecessary risks to the DS0000046439.V340496.R01.S.doc 5. OP33 24(1) 01/10/07 6. OP38 12, 13(4) 23(2)(c), 23(4)(c) 01/09/07 The Manse Version 5.2 Page 27 health or safety of service users are identified and so far as possible eliminated. Any equipment provided at the care home for use by service users or persons who work at the care home is maintained in good working order (For example: 1. Emergency lighting must be tested at intervals recommended by the fire authority. 2. There must be suitable testing and records of this, regarding testing to prevent Legionella. 3. There must be satisfactory evidence the electrical hardwire circuit is safe. Documentation confirming the circuit is satisfactory must be forwarded to the Commission. ) 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. 3. Refer to Standard OP7 OP9 OP12 Good Practice Recommendations Care plans should include a personal history of each service user. Improve the medication returns system so there is a better system of audit. The registered manager should arrange a regular survey to ascertain when individual service users wish to have their breakfast. The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Manse DS0000046439.V340496.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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