Care Home: Manor House

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What the care home does well Prospective residents have access to a good standard of information to assist them in their decision where to live and there are good systems in place to ensure the home can meet their needs. One person wrote in their survey, "I am happy". Visitors told us that they were very satisfied with the standard of care provided to their relative. We were told that the home provides a "personal touch" and "My mother is always kept warm, clean and comfortable".Visitors and residents told us that the staff were "very good". The results of the BUPA survey for 2007 were seen and, for the person being treated as an individual, the home scored a 94% rating for excellent/good. People have a choice of a cooked breakfast to include egg and bacon, egg on toast, boiled egg or cheese on toast. People are listened to and are safe from the risk of abuse. People can be confident that they receive safe care from staff who are on the whole, well trained and well recruited. People benefit from a generally well-managed and safe home. The environmental health officer, in August 2008, rated the kitchen area to be of an "excellent standard". What has improved since the last inspection? The security for medicines in use has improved and the requirement made on the last inspection about this, has been met. We have received required information about progress in making part of the home, South Wing, safer. This requirement has been met. The range of activities has improved. CARE HOMES FOR OLDER PEOPLE Manor House 80 Huntingdon Road Upwood Huntingdon Cambridgeshire PE26 2QQ Lead Inspector Elaine Boismier Unannounced Inspection 30th September 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Manor House DS0000024320.V371410.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. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor House Address 80 Huntingdon Road Upwood Huntingdon Cambridgeshire PE26 2QQ 01487 814333 01487 710083 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) www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Manager post vacant Care Home 43 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (38), of places Physical disability (1), Physical disability over 65 years of age (38) Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The number of nursing care places may not exceed 27 at any one time One named male under 65 years of age with physical disability for the duration of their residency. The number of places for OP and PD(E) may not exceed 38 for the duration of conditions number 2 and 4 The number of places for DE(E) may not exceed 4 at any one time The total number of people accommodated in the home may not at any one time exceed 43 9th January 2008 Date of last inspection Brief Description of the Service: Manor House is an adapted 19th Century domestic dwelling located in the small village of Upwood, about 3 miles from Ramsey. The building, that has served as a vicarage and later a surgical unit for overseas military, is arranged on two levels with well-maintained gardens to the front of the home. Parking is available to the front of the home. Accommodation is on two floors, with a lift to the first floor. The home is registered to provide accommodation, care, including nursing care, for a maximum number of 42 service users over 65 years of age. Applications for minor variations of registration have been approved for 4 places for people over 65 years of age with dementia and for one named person under 65 years of age with a physical disability. Current fees range from £358.06 to £630. Additional costs include those for chiropody, hairdressing and newspapers. Further information about fees can be obtained from the home. A copy of the inspection report is available on request at the home or via the CSCI website at www.csci.org.uk Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We, The Commission for Social Care Inspection, carried out this key unannounced inspection by three Inspectors between 10:00 and 15:45, taking 5 hours and 45 minutes to complete. Some of the people living at Manor House are not able to say what it is like living there. So an Inspector spent some time observing and recording the experience of some of the people using the service. This activity is called short observational framework for inspection (SOFI). We were unable to spend the full 2 hours carrying out this activity, as we like to, so we used the remaining time to watch activities, in the dining room, at lunchtime. We looked around the premises, spoke with visitors, the staff, some of the residents and the Manager. We watched the staff working, observed some of the people and looked at documentation. Before the inspection we looked at information we have received about the home, since our last inspection in January 2008, and we received surveys and a completed Annual Quality Assurance Assessment (AQAA). All of the above sources have provided information about the home and some of this has been referred to in this report. For the purpose of this report people who live at the home are referred to as “people”, “person” or “resident/s”. What the service does well: Prospective residents have access to a good standard of information to assist them in their decision where to live and there are good systems in place to ensure the home can meet their needs. One person wrote in their survey, “I am happy”. Visitors told us that they were very satisfied with the standard of care provided to their relative. We were told that the home provides a “personal touch” and “My mother is always kept warm, clean and comfortable”. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 6 Visitors and residents told us that the staff were “very good”. The results of the BUPA survey for 2007 were seen and, for the person being treated as an individual, the home scored a 94 rating for excellent/good. People have a choice of a cooked breakfast to include egg and bacon, egg on toast, boiled egg or cheese on toast. People are listened to and are safe from the risk of abuse. People can be confident that they receive safe care from staff who are on the whole, well trained and well recruited. People benefit from a generally well-managed and safe home. The environmental health officer, in August 2008, rated the kitchen area to be of an “excellent standard”. What has improved since the last inspection? What they could do better: The standard of care records could be better. Where people are prescribed medication on a “when required” basis, there is a need for detailed information for staff on what such medication is used for and how it should be used. A requirement has been made about this to safeguard residents and protect them from the risk of harm. The monitoring of all people’s weights could be better. We expect the home to manage this issue rather than we make a requirement on this occasion. We expect the standard of people’s nail care to be better. We expect the home to manage this issue rather than we make a requirement on this occasion. Individual attention, paid to residents, at lunchtime could be better. We expect the home to manage this issue rather than we make a requirement on this occasion. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 7 People live in home that could be safer and better maintained. A new requirement has been made about South Wing. Where structural cracks have appeared in external walls of the building we expect the home to manage this issue rather than we make a requirement on this occasion. Any gap in any member of staff’s employment history must have a written explanation about this, before they are allowed to work at the home. We expect the home to manage this issue rather than we make a requirement on this occasion. 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. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 Quality in this outcome area is good. Prospective residents have access to a good standard of information to assist them in their decision where to live and there are good systems in place to ensure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the 10 residents’ surveys said that the person received enough information about the home to help them in their decision where to live. According to the AQAA no resident, within the last 12 months, has needed to move out of the home indicating that the home considers it has been a suitable place for any of the residents admitted there. The current Statement of Purpose is under review although it provides a good standard of information about the home. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 10 Examination, with the Manager, of two people’s care records, indicated that the home obtains assessments and information about the person before they move into the home, including any emergency admissions. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. People are generally safe and well cared for although some of the individualised care and the standard of record keeping could be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Visitors, we spoke with, told us that they were aware of their relative’s care plan and had been actively consulted about these records. Minutes of a residents’/relatives’ meeting, held on the 27th September 2008, indicated that care plan documentation, and reviews of the residents’ care, was an agenda discussed during this meeting. Although the care plans were generally of a good standard, providing clear guidance for staff in how to meet the residents’ assessed needs and to manage any risks identified, there were some areas that required further attention. For example a person recorded as having recurrent chest infections had no specific risk assessment or care plan about this recurring medical condition. Where Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 12 people are prescribed medication on a “when required” basis, there is a need for detailed information for staff on what such medication is used for and how it should be used. For example, a person prescribed medication to control behaviour had no detailed care plan for this and when the medication was used, no record was made to justify its use. The care plans were actively reviewed each month. All of the 10 residents’ surveys said the person always/usually received the care, including medical care, and the support that they needed. One person added, “I am happy”. All of the 4 surveys from relatives said that the home always/usually met the needs of the resident that they were linked with although one of these surveys said that more attention to detail could be made in that “(I) would like more of the personal touch i.e. making sure nails are kept clean and cut; nail polish used; hair always brushed; co-ordinated selection of clothing”. We noted that one of the two people we cased tracked (outside of the SOFI) their nails were clean whereas the other person, who needed help with their personal care, had dirt under their fingernails. According to the AQAA, within the last 12 months, one person has acquired a pressure sore whilst living at the home, and during the inspection the Manager informed us that there was no person, currently living at the home, who had such a sore. People’s weights were generally recorded each month and there was evidence that the body mass index was actively reviewed in response to the recorded weights. It was noted that for one person, who had a record of unintentional weight loss, they had declined the offer of being weighed and no further offer had been made to them until 4 weeks when they were next weighed. Visitors told us that they were very satisfied with the standard of care provided to their relative. We were told that the home provides a “personal touch” and “My mother is always kept warm, clean and comfortable”. During a telephone conversation with a representative of BUPA Care Homes (CFCHomes) Limited, the registered owner of the home, in August 2008, we were informed that it is intended for a separate hair dressing salon to be created as part of the changes to the building of the home. A pharmacist inspector examined practices and procedures for the safe use, handling and recording of medication. Medicines storage facilities were secure and the temperatures monitored regularly to maintain the quality of medicines in use. The storage temperature is at the high side of acceptable and this had been noted by the Manager who said that this will be kept under review and if necessary cooling systems will be put in place. Records made when medicines are received into the home, given to resident and disposed of are generally of good quality and provide evidence that residents receive their medication was prescribed. There were a few gaps in the records made when medication is Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 13 given to people, but not at a level to cause concern. The Manager carries out regularly audits on medication in use and this is good practice. We watched some medicines being given to residents at lunchtime and this was done with due regard to their personal choice. The Manager told us that people are only given medication by suitably trained care staff but no record could be found in the training files inspected of what training was provided or that they had been assessed as competent to do so. We expect this to be managed by the home rather than make a requirement on this occasion. We noted that the staff interacted with the residents in a dignified and friendly manner, during times when the staff were going into people’s rooms, at lunch time and when people were sitting in the lounge areas. Visitors and residents told us that the staff were “very good”. The results of the BUPA survey for 2007 were seen and, for the person being treated as an individual, the home scored 94 rating for excellent/good. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. People are provided with opportunities to live a good standard of life although individual attention paid to residents, at lunchtime could be better. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Seven of the 10 residents’ surveys said that the home usually provides activities that the person can take part in whereas the remaining 3 surveys said that the home sometimes provided such activities. One comment was that the activities co-ordinator was now working in a different role although the AQAA said that there had been a successful recruitment of a new activities coordinator. One of the relative’s surveys said that they would like people to be helped to go out into the garden more, when the weather permits. The people’s care records that we examined indicated that the activities provided, including for those people who wish to stay in their rooms, has improved, to include visits by pat dogs and 1:1 reading. Visitors of one person said that the staff always put on the type of music their relative liked to listen to. One of the people said that they were taken out, by their family to the local Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 15 pub and had a meal there and this was confirmed by what the Manager told us. One of the people told us, and this was confirmed by the minutes of the residents’/ relatives’ meeting held on the 27th September 2008, that the home had held a cream tea party for the residents and their guests to attend. The day before our inspection the home received a number of chicken eggs waiting to be hatched. The people’s care records indicated that they had seen the eggs and there were records of the people’s positive responses to such an activity. All of the 4 relatives’ surveys said that the home always/usually gave the support to the resident they were linked with, to live their life how they choose to. We saw people getting up in a leisurely manner and people we spoke with said that they could chose to stay in their room if they wanted to. Visitors to the home said that they could visit any time they wanted to. People we spoke with, and confirmed in their care records, that they can receive their guests when they like. Nine of the 10 residents’ surveys said that the person always/usually liked the meals whereas the remaining surveys said that sometimes the person liked the meals. The AQAA said that the home has improved, within the last 12 months as there has been an introduction of the “Bupa Night Bite system to ensure that food is available 24 hours a day”. Records indicated that people have a choice of a cooked breakfast to include egg and bacon, egg on toast, boiled egg or cheese on toast. People we spoke with said that the food was “good” and that there was a choice. The main dining room had tables that were well presented with table linen and flower decorations and the menu for the day. During the last inspection, in January 2008, it was noted that there was an insufficient number of staff to help during the lunch time period and a recommendation was made about this. During this inspection it was the view of one of the visitors that there was not always enough staff on duty during this busy period. We observed activities between 12:45 and 13:20, in the dining room, and it was noted that some of the care practices could be better. Although a care plan for one person stated that the person needed 1:1 supervision at meal times this did not happen and the person ate their food off their knife. For another person their care plan stated that this person needed prompting and encouragement to eat although this did not happen. This person, who had a record of unintentional weight loss and a low body mass index, ate two mouthfuls of food and none other during our time we spent in the dining room. Two other residents were seated in the dining room although they had received none of their meal during our time we spent observing. Choices, of what people would like to drink and if they would like gravy on Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 16 their food, were not always offered. We expect the home to improve the mealtime experience for people. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 17 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 good. People are listened to and are safe from the risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the 10 residents’ surveys said that they knew who to speak to if they were unhappy about something and all of the 10 residents’ surveys and all of the 4 relatives’ surveys said that the person knew how to make a complaint. The relatives’ surveys said that the person was satisfied with the home’s response to any concerns that they had shared with the home. All of the 3 staff surveys said that the person knew what to do if any person living or visiting the home had concerns about the home. All of the 10 residents’ surveys said that the staff listened to and acted on what the person said to them. Since our last inspection, in January 2008, we have received two concerns about the standard of care provided at the home. We spoke with a representative of the registered provider and we agreed that such concerns should be dealt with by the home. Examination of the record of complaints for this last concern indicated that the response to the concern was within the 28 required time period and the response was that of a listening nature. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 18 According to the AQAA the home has received 4 complaints within the last 12 months of which 75 of these had been resolved within 28 days. The AQAA said that one of these 4 complaints had been proven. Since our last inspection we have received no allegation of abuse against any of the residents and the AQAA also told us the same. The AQAA told us that “PoVA training has been rolled out to all staff.” (POVA means protection of vulnerable adults against abuse, of which we now call SOVA or safeguarding adults against abuse). Although the staff training records indicated not all of the staff have attended SOVA training, the staff we spoke with said that they knew what to do if an incident of abuse had occurred against any of the residents. The response they gave was satisfactory. One of the relative’s surveys said, “They (the staff) are very kind and caring people”. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 19 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 adequate. People live in a home that is clean but could be more suitable and safer. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement has been made for the South Wing of the home to be made safer to ensure that any person working or living in this area is safe from the risk of harm. The requirement asked specifically for information about the progress on making this area of the home safer. During telephone conversations, in August 2008 and again at the time of this inspection, with a representative of the registered owner, we have received this required information. According to the Manager people who live on the South Wing are independent with walking about and transferring from bed to chair, thereby they do not need the assistance of moving and handling equipment. Nevertheless there remains a risk to any person living or working in this area, Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 20 in the event of an emergency situation. We have made a new requirement about the South Wing. The home was generally well decorated and according to the Manager arrangements have been made for the replacement of some of the carpets and curtains. During our tour of the external parts of the home we noted two areas of an external wall had “zigzag” cracks. The external window, of room number 14, had come way from the surrounding brickwork. The Manager agreed to establish if any survey work has been carried out in this area. All of the 10 residents’ surveys said the home was always/usually clean and fresh and we found this was the case. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 21 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 good. People can be confident that they receive safe care from staff who are on the whole, well trained and well recruited. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the 10 resident’s surveys said that the staff were always/usually available when the person needed them although one of the relative’s surveys said that they would like to be able to see the staff more when they come into the home. The 3 staff surveys offered a range of views about the number of staff on duty: one said that there was always enough staff on duty; another said there was usually enough staff on duty whereas the final survey said sometimes there was enough staff on duty. This last survey said “I strongly believe it is impossible to render very high quality of care with 6 carers and 1 nurse in a 40 bed nursing home with high dependency nursing residents.” We spoke with the staff and it was considered that although there might be enough staff on duty it was the turnover of staff that might have a direct impact on the quality of care provided, due to new and less experienced staff working at the home. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 22 Two visitors, who we spoke with, held the view that there was always enough staff on duty whereas another visitor felt that this was not always the case (See Standard 15 of this report). Since our last inspection there has been re-organisation of how care is provided. Two teams have been developed and the staff felt that this had improved how care is delivered as there was direct leadership and the staff were aware of their individual responsibilities. We discussed, with the Manager, our observations of the activities during the lunchtime period and although there may or may not be enough staff on duty there could be a case of how the work of the staff is organised. We expect the home to take action in response to our findings, rather than we make a requirement on this occasion. The AQAA told us that of the 30 members of care staff, 21 of these have a National Vocational Qualification level 2, or equivalent, in care i.e. 70 . Three staff recruitment files were examined and all of the required information was available with the exception of an unexplained gap in one of the staff’s employment history that was between 17th May 2006 and the 1st September 2006. We expect the home to take action in response to our findings, rather than we make a requirement on this occasion. All of the 4 relatives’ surveys said that the staff always/usually had the right skills and experience to look after the people properly. One of these surveys said, “As far as I know they are very good”. The AQAA said that 30 of the staff have attended training in the prevention and management of infection and the staff we spoke with said that they have attended, or are attending training in customer care and tissue viability. All of the 3 surveys from staff said that the person had received induction training that covered everything they needed to know about the job and they had received ongoing training that kept them up to date and able to meet the needs of the residents. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 23 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 good. People benefit from a well managed and safe home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In May 2008 we received written notification, from the registered provider, informing us of a change of home manager. The Manager is a registered nurse, having previous clinical experience in a care home and in hospitals. She is in the process of applying to be the registered manager of the home. The staff and visitors we spoke with said that they had confidence in her abilities to continue to improve the standards of care and management of the home. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 24 The AQAA was completed to a satisfactory standard and it highlighted areas that the home does well in, what has improved within the last 12 months and it identified areas where improvements could be made. Two of the most recent copies of the regulation 26 reports, made by representatives of the registered owner were seen and these demonstrated that audits were carried out on areas such as care plan documentation, complaints, health and safety and medication. We do not know the views of any of the people, including the residents and the staff, about the home, as none were recorded. The results of the survey for 2007, carried out by BUPA, indicated that the Manor House achieved 85 for an “overall satisfaction” rating. Accounts for people’s personal monies were seen and, according to the staff, any personal monies received are deposited directly into an interest account, in people’s individual names. Receipts are provided although, due to the (temporary) failure of the home’s computer system, we were unable to cross reference any recent transactions made. According to the AQAA, safety checks have been carried out, in 2008, for fire detection and fire fighting equipment, portable appliance equipment and for lifts and hoists. Records for fire alarm tests, emergency lighting and temperatures of hot water in baths were satisfactory. The environmental health officer report, for their inspection of the 1st August 2008, of the kitchen stated that there were “excellent standards observed”. The last fire safety officer report, following their inspection in October 2007, indicated that the “outcome (was) satisfactory”. Arrangements are in place for all staff to attend refresher training in fire safety and the two staff training records we saw indicated that these people have attended refresher training in safe moving and handling. Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 25 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Where people are prescribed medication on a “when required” basis, there is a need for detailed information for staff on what such medication is used for and how it should be used. This will safeguard residents and protect them from the risk of harm. Timescale for action 31/10/08 2. OP19 23(1) The South Wing part of the home 01/06/09 must be more suitable to ensure that no person’s health and safety is compromised during any untoward event. 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 Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Manor House DS0000024320.V371410.R01.S.doc Version 5.2 Page 28 - 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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