Inspection on 21/01/06 for The Manse

This inspection was carried out on 21st January 2006.

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 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 16/07/07

The Manse 02/02/06

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 08:30 21st and 22 August 2006 nd 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.V306759.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.V306759.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.V306759.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 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 singles. All bedrooms have 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. Day care for up to two service users can be 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 £298 to £360 per week. There are additional charges e.g. for hairdressing, chiropody, and newspapers etc. The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place in sixteen and three quarter hours over two days. All of the key standards were inspected. The methodology used for this inspection was: • To case track five service users. This included, where possible, meeting and discussing with the service users their experiences, and inspecting their records. • Discussing with five staff their experiences working in the home. • Discussion with other service users and their representatives. • 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 eleven statutory requirements. These need to be actioned by law within the timescales set. This is an above average number of requirements for this home. An improvement plan has been requested to outline how the registered persons intend to address the issues of concern. The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 6 Information issued to service users at the time of admission needs to be improved. This needs to accurately reflect the service e.g. now that up to 16 service users with dementia can be admitted. All service users must have either an individualised copy of the home’s terms and conditions of residency or a contract within their service user guide. Improvements need to be made to the storage, administration, recording and disposal of medication. All wheelchairs should have footrests to help avoid accidents. The registered persons have recently unilaterally reduced staffing levels. The Commission for Social Care Inspection requires a report and risk assessment from the registered provider. This should outline why these changes were made and how appropriate care can be given to service users. Although recruitment checks are generally satisfactory, one member of staff did not appear to have any references. No documentation confirming identification was obtained for at least two members of staff as required by regulation. Staff induction and training have improved, although there are still some gaps in training required by regulation and to meet the needs of service users. There needs to be written records regarding staff induction for all staff- for a minority of staff these records were not available. The registered persons need to develop a quality assurance policy as required by regulation. Gas appliances must be tested at least annually and a safety certificate obtained. 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 Manse DS0000046439.V306759.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.V306759.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. The registered provider’s statement of purpose and service user guide needs updating, so service users and their representatives have correct information about services offered. All service users must have a copy of terms and conditions of residency or a contract, so they are aware of their rights and responsibilities. The pre admission assessment procedure is good, and enables the registered persons to ascertain they can meet the needs of service users, before admission is arranged. EVIDENCE: Copies of the registered provider’s statement of purpose and service user guide were inspected. These need to be updated to outline the recent changes in registration i.e. the home now can admit up to 16 service users with dementia. The documents need to outline how these peoples’ needs will be met. These documents need to be available for inspection and to service users. The registered manager said she provides a copy of the service user guide when she assesses service users. However the service user guide should be issued to service users when they are admitted to the home (and to the service users representatives if this is applicable.) It should for example The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 9 include an individualised copy of terms and conditions of tenancy / residents contact. A suitable copy of the home’s statement of terms and conditions of residency / contract was inspected. A copy of this document was on some service user files, but absent from others. The registered manager said terms and conditions / contracts had not been issued to service users who were present before the current owners took over the home. The registered provider must ensure service users who are funded by social services at least have a copy of a social services contract on file, and preferably a signed copy of the home’s terms and conditions of residency. Service users who fund their own care must have a signed contract on individual files. Service users and (where appropriate) their representatives should receive a signed copy of appropriate documentation (irrespective of funding arrangements). The registered provider assesses service users before they are admitted. The registered manager said service users or their relatives could visit the home before formal admission is arranged. Some service users said an assessment was completed before admission was arranged, although others could not remember this happening. Copies of assessments were available for inspection in service user files. The Manse DS0000046439.V306759.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this area is overall adequate. The judgement has been made using available evidence including a visit to the service. All service users have a care plan, although some work needs to occur to ensure all care plans are comprehensive and are appropriately reviewed. This will help to ensure service users’ care needs are suitably met. Healthcare support seems appropriate so service users can be assured they will receive suitable support from medical practitioners. The operation of the medication system is poor, and appropriate action needs to take place by the registered persons, so service users can be assured their medication is handled appropriately. Issues regarding the diverse backgrounds of service users appear suitably addressed. Service users have said they feel they are treated with respect and dignity. EVIDENCE: There is a copy of a care plan in each service user file. Staff said care plans were accessible to them. The care plan format is basic but satisfactory. However information regarding service users’ religion needs to be included in care plans. Some care plans need to be more comprehensive, as for example, some of the sections have not been completed. National minimum standard 3 outlines what information should be included in any care plan. Some care plans need to be reviewed more regularly, and the date of when the care plan is reviewed should include the year. Service users the inspector spoke to did not The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 11 seem aware of care plans and did not seem to have any involvement in their development and review. Service users however said care is delivered to a good standard, and staff did their best to meet service user needs. Service users wheel chairs did not have footrests attached. This is potentially unsafe, and needs to be rectified. The registered manager said one service user refused to have the foot rests attached to their wheelchair. Where this is the case the matter needs to be risk assessed. Service users said they were satisfied with the healthcare support they received. This includes visits from GP’s, district nurses, chiropodists, dentists and opticians. The inspector spoke to two district nurses who were very happy with care practices within the home. GP visits were recorded appropriately, but visits by other medical professionals should be recorded separately from the daily notes. Current practice makes it difficult to track, for example, when a service user last saw a dentist. The registered providers have a satisfactory medication policy. Medication is administered via the monitored dosage system. The medication system was inspected. The following issues must be addressed: • Administration. Staff must sign for each service user’s medication at the time of admission and not retrospectively. Diazepam medication for one service user, which was prescribed as PRN (‘as required’), was being administered each day three times a day. The manager said she would clarify whether the service user was requesting this or whether there is a misunderstanding regarding the GP’s instruction. • Record keeping. Some medication was signed for when it was not administered, and some medication was not signed for when it was administered. All medication kept in the home must be recorded on medication sheets. • Storage. Medication which is no longer required must be disposed of via, for example, the pharmacist. One of the medication cabinets was not affixed to the wall and this must be rectified. There was also not sufficient light in the hallway where one of the upstairs medication cabinet’s is situated. Some medication was also kept outside the medication cabinet and this must be rectified. There was over supply of some medication. Where necessary this must be returned to the pharmacist and care must be taken not to obtain more medication than is required, when medication is ordered. Some medication also had labels removed and appeared to be for general use e.g. Lactulose and Gaviscon. Medication administered to individuals must be prescribed to them only. The operation of the medication system is unsatisfactory, and the registered manager must take urgent action to ensure the above problems are rectified. The registered manager should consult the Royal Pharmaceutical Society Guidelines as a baseline regarding how the system needs to operate. The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 12 Service users said they felt staff worked with them in a manner, which respected their privacy and dignity. Service users were positive about their care. Service users said personal care was provided to a good standard. The registered provider has a satisfactory policy regarding anti discrimination. There are currently no service users from ethnic minorities, although the registered persons stated they would be more than happy to accommodate service users from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Issues regarding sexuality, gender and disability seem to be suitably addressed. The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. Routines and activities are satisfactory so service users can live a lifestyle that meets their needs. Visiting arrangements are flexible. Appropriate arrangements appear to be in place regarding the management of service user monies. Meals are provided to a good standard, so service users receive a wholesome and nutritious diet. EVIDENCE: Service users said they could get up and go to bed when they wished. The inspector observed staff working in an appropriate matter with service users. The morning routine of assisting service users to get up was unrushed and appears to take individual wishes and needs into consideration. Service users either spend time in one of the lounges or in their bedrooms. There are some organised activities for example bingo and keep fit. An entertainer visits every two months, and occasional trips are organised. Other activities such as board games and singsongs are organised. Service users said they could receive visitors when they wished. The registered manager said a Church of England minister visits monthly, and one service user has a Methodist minister visiting. One service user who the inspector spoke to was not aware of religious ministers visiting. It is important any religious needs are recorded in care plans, and activities / religious The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 14 services are publicised. Service users said the library visits the home on a regular basis. One service user commented that they did not see a member of staff from teatime (approx. 5pm) until 9pm and could get lonely. The registered manager said she would address this issue. Some monies are maintained on behalf of service users, and these are stored securely. The registered manager said records are maintained for any small sums of money kept on behalf of service users. Service users said they either control their own finances or they have power of autonym arrangements. Although service users are not issued with a security box, all bedroom doors are lockable. Service users said they felt there personal belongings were safe and secure in the home. Service users have their meals either in the downstairs dining room, or the upstairs downstairs lounge / dining room. Some service users have their meals in their bedrooms. The inspector shared lunch with service users on both days of the inspection, in both communal areas. The meals were to a good standard. All Service users said they enjoyed the food provided. A choice of a hot and cold evening tea is offered. 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, service users said staff were aware of preferences, and an alternative is provided where necessary. One service user said sometimes crockery and cutlery was dirty, but the inspector found no other evidence of this. The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. The registered persons have suitable procedures regarding complaints and adult protection. Subsequently service users can be assured there are appropriate procedures to deal with any concerns or bad practice. EVIDENCE: The registered persons have satisfactory procedures regarding complaints and adult protection. Staff and service users 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. Complaints received by the registered persons were appropriately recorded and appear to be suitably resolved. The Commission for Social Care Inspection has not received any complaints since the last inspection. The registered manager has arranged some training regarding abuse and adult protection. The registered manager is also trying to get places on local authority adult protection training, although this is proving difficult due to lack of spaces available. Staff and service users all said they had not witnessed any bad or abusive practices. All staff have Criminal Record Bureau check, and a Protection of Vulnerable Adults check (where applicable). The Manse DS0000046439.V306759.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. The Manse provides a pleasant, homely, clean and well-maintained environment for service users to live and feel at home in. EVIDENCE: The building was inspected. The building appears to be well maintained, clean, pleasantly decorated and homely. There is a pleasant garden, which service users can use. All communal rooms are homely and comfortable. There are two lounges-one upstairs, and one downstairs at the front of the house. There is also a conservatory, which sadly does not currently appear to be used. Bedrooms are individualised and comfortable. A stair lift is provided to assist service users to go upstairs. The majority of decorations are maintained to a high standard, although one gentleman’s bedroom looked like it now needs redecoration. 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. However the The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 17 toilet seat in this bathroom was broken, although the registered manager said she would get it fixed when the inspector reported the matter. Suitable kitchen and laundry facilities are provided. Cleaning staff are employed, and the home was clean and hygienic at the time of inspection. The Manse DS0000046439.V306759.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. Staffing levels do not appear satisfactory. Further information is required by the Commission for Social Care Inspection regarding the recent reduction in staffing levels. Recruitment records are generally satisfactory, although two references and evidence of checking staff identity needs to be obtained, when staff are recruited. This will help assure service users that they are in safe hands. Although staff training has improved, there are still some gaps in training required by regulation. Staff need to be trained so they have an awareness of the needs of people with dementia. These measures will assure service users that staff have suitable skills and knowledge to cater for their needs. The registered provider has a good approach to ensuring staff have a national vocational qualification in care. Equal opportunities issues regarding recruitment and work practices seem satisfactory. EVIDENCE: Rotas show three members of staff are on duty in the morning, at least two in the afternoon, and two staff in the evening until 2200. There is one waking night staff on duty from 2200 to 0730, and one member of staff sleeping in. Staffing levels have recently been reduced from three members of staff to two members of staff in the evening. The registered persons did not consult the Commission for Social Care Inspection regarding this change. The commission has recently agreed to allow the registered persons to admit up to sixteen people with dementia. The commission expected staffing levels to increase as The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 19 more people with dementia were admitted to the home. It is of concern staffing levels have decreased. The inspector received some concerns regarding the decrease in staffing. The registered manager said staffing levels had decreased due to service user vacancies, and the subsequent financial pressures. The registered persons must provide a risk assessment and report outlining the rationale behind the changes, and how service users needs can be met with this level of staffing. The registered providers have a suitable approach to providing National Vocational Qualifications for care staff. Currently 66 of staff have an NVQ 2 or 3. Five other staff are also in the process of obtaining an NVQ 2 or 3. Staff training records were inspected. Staff training required by regulation needs some improvement although it has developed well since the last inspection. There must be at least one member of staff with a first aid certificate (at appointed persons level) on duty at any time. Some staff need to have fire, manual handling, infection control and food handling training, although the majority of staff appear to have received this training. The majority of staff are currently receiving training in dementia awareness. Some staff still need to commence this, and all staff need to complete the course. Some staff have received additional training regarding health and safety, diabetes, and pressure sore care. Staff who administer medication appear to be trained appropriately. Most staff have a satisfactory record of their staff induction, although this was absent for two members of staff. The previous requirements regarding staff induction and staff training are subsequently renotified. Recruitment records were inspected. Many staff have been employed for some time. Most recruitment and personnel records were satisfactory, although there were no references on file for one member of staff. The previous requirement regarding staff references is renotified. Records confirming identity (e.g. copy of passport) were also absent for two members of staff. There are suitable records regarding staff supervision for most staff. The registered provider’s approach to equal opportunities and anti discrimination is satisfactory. The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. The registered persons appear to be suitably experienced and qualified to manage the home. It is of some concern the number of statutory requirements this inspection has generated. An improvement plan has been requested from the registered persons. The registered persons approach to quality assurance needs development. This will assist the registered persons to improve the quality of service. The registered persons approach to handling service users monies is satisfactory, so service users can be assured their financial interests are safeguarded, where the registered persons are involved in this area of their lives. The management of health and safety issues is generally satisfactory although gas appliances need to be serviced annually. EVIDENCE: The registered persons appear to have suitable experience and knowledge to manage the home. There is no structured approach to quality assurance. For example there is no quality assurance policy, and although the registered The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 21 persons attempted to survey stakeholders regarding their views there appears to be only one response. However the staff team have received some letters and cards of thanks from relatives for care given to service users. Staff meetings also take place, and there is a residents forum which was set up by a group of service users and attended by the registered manager. The registered persons need to develop a quality assurance policy, and further develop suitable methods to measure service quality. The inspector gave some guidance to the registered manager regarding this issue. The registered persons look after some service user monies, for which suitable records are maintained. The registered persons do not act as agents for service user government financial benefits. The registered provider has a health and safety policy. Records kept of checks required by regulation are generally satisfactory. For example there are suitable records for the testing of fire equipment, moving and handling equipment, electrical appliances and the electrical hardwire circuit. Accident records are suitably maintained. Health and safety risk assessments are satisfactory. There is a suitable risk assessment regarding the prevention of Legionella, and appropriate control measures are in place. There are some gaps in health and safety training as highlighted in the ‘Staffing’ section of the report. The gas appliances appear to be last serviced in February 2005, this needs to be actioned and a gas safety certificate obtained. The registered manager said the oil central heating was last serviced recently, and the home is awaiting a safety certificate regarding this. The current documentation on file regarding this shows the system was last serviced in October 2004. The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 22 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 2 2 3 X X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 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 2 X 2 X 3 X X 2 The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 4,5,6 Requirement Timescale for action 01/11/06 2. OP7 3. OP7 The registered persons must: • Update the home’s statement of purpose and service user guide so they accurately reflect the services offered. • Issue the service user guide to all service users. New service users should be issued with the documentation at the time of admission. 12, 13, 15 The registered manager must: 01/11/06 • Ensure all service users have a comprehensive care plan with all relevant information to enable staff to meet their needs. • Care plans must be suitably reviewed preferably on a monthly basis. Reviews should be fully dated and involve the service user where possible. • Keep suitable records of all medical interventions e.g. dentists, chiropodists etc. 12, 15 Wheel chairs must be fitted with 01/11/06 footrests. If a service user DS0000046439.V306759.R01.S.doc Version 5.2 The Manse Page 24 4. OP9 13 5. OP27 7, 9, 12, 13, 18 refuses to have foot rests fitted to their wheelchair, the matter should be risk assessed. The registered persons must 04/09/06 operate a suitable system for the storage and administration of medication (for example in line with the Royal Pharmaceutical Society guidelines.) The registered persons must 04/09/06 provide the Commission for Social Care Inspection with a risk assessment and report outlining the rationale behind staffing level changes, and how service users needs can be met with the current staffing levels. The registered persons must ensure: Two references are obtained for new staff employed. Timescale of 01/03/06 not met. Second Notification. Evidence confirming the identity of new staff is obtained when staff are recruited. The registered persons must ensure staff receive training appropriate to the work they perform: • This must include training required by regulation for example fire, first aid, infection control, food handling, manual handling. Timescale of 01/06/06 not met. Third Notification. • All staff must receive training regarding dementia awareness. Version 5.2 Page 25 6. OP29 19 04/09/06 • • 7. OP38 13, 18 01/11/06 The Manse DS0000046439.V306759.R01.S.doc 8. OP30 18 All staff must receive an induction and there must be documentary evidence of this. 01/03/06 9. OP31 7, 9 10. OP33 24 11. OP38 13, 23 Timescale of 01/03/06 not met. Second Notification. The registered persons must 01/10/06 provide the Commission for Social Care Inspection with an improvement plan regarding how they will address the statutory requirements highlighted in this report. The registered persons must: 01/11/06 • Develop a suitable policy regarding quality assurance. • Ensure further methods are adopted to measure service quality. The registered persons must 01/10/06 ensure gas appliances are serviced and a gas safety certificate is obtained on an annual basis. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 The Manse DS0000046439.V306759.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!