Care Home: Manor House (The)

Similar services:

• Abbey The
• Snydale Care Home
• Hawkhills
• Larchfield Manor
• Beeches The - North Yorkshire County Council
• Carentan House
• Ravensworth Lodge

What the care home does well People are only offered a place at the home following a thorough assessment of their needs and if it is considered that their assessed needs can be met. The health care needs of residents are met, including the provision of pressure care equipment and the safe administration of medication. Residents are encouraged and supported to live their chosen lifestyle and to take part in appropriate activities. This includes one to one activities for those people who like to go out for a walk or to remain in their own room. The home is well maintained, clean and hygienic, providing comfortable and safe surroundings for residents. Staff take part in training programmes that equip them to meet the needs of residents living at the home. The home is well managed and the quality assurance system gives residents and others the opportunity to affect the way that the home is operated. The health and safety systems in place are audited on a regular basis to ensure that they are effective. What has improved since the last inspection? The procedures and practices regarding the administration of medication have improved; medication is returned to the pharmacist at regular intervals, staff have had appropriate training and medication administration records are signed at the time that medication is administered to residents. Medication is now administered safely and this protects residents from harm. All staff have now been issued with a statement of terms and conditions of employment. Relatives are now included in the quality assurance process and are able to affect the way in which the home is operated. Staff now receive formal supervision six times per year. This gives them the opportunity to have a one to one meeting with their line manager to discuss any concerns or queries about individual residents or care practices in general. CARE HOMES FOR OLDER PEOPLE Manor House (The) White Gap Road Little Weighton Nr Beverley East Yorkshire HU20 3XE Lead Inspector Diane Wilkinson Key Unannounced Inspection 26th June 2008 10:30 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 (The) DS0000066138.V367228.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 (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor House (The) Address White Gap Road Little Weighton Nr Beverley East Yorkshire HU20 3XE 01482 848250 01482 843740 themanorhouse@parklanehealthcare.co.uk 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) Park Lane Healthcare (The Manor House) Ltd Mrs Karen Pauline Bird Care Home 38 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (38), Old age, not falling within any other of places category (38) Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th June 2006 Brief Description of the Service: The Manor House is a converted Victorian farmhouse standing in its own grounds in the village of Little Weighton, near Beverley. The home is registered to provide care and accommodation for thirty-eight older people, including those with dementia related conditions. Private and communal accommodation is provided over two floors and there is a passenger lift to provide access to the first floor. Many of the bedrooms have views over the surrounding countryside and spacious gardens. There are three lounges and a separate dining room. A large conservatory provides access to outside areas where service users can sit and enjoy the gardens. The home’s administrator told us that the current weekly accommodation fees range from £350.00 to £550.00 per week. This information is available for residents and others in the Statement of Purpose and Service User’s Guide. Manor House (The) DS0000066138.V367228.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. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on 27 June 2006, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 10.30 am and ended at 4.35 pm. On the day of the site visit the inspector spoke on a one to one basis with three residents, a relative, three members of staff and the registered manager. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The registered provider and registered manager submitted information about the service by completing and returning an Annual Quality Assurance Assessment (AQAA) form. The AQAA is a selfassessment that focuses on how well outcomes are being met for people using the service. A random inspection was undertaken on 28 September 2006 as a result of information received by the CSCI. This inspection is recorded in a random inspection report of the same date; random inspection reports are not public documents but the registered provider has a copy of the report that should be made available to enquirers. An annual service review was undertaken on 24 January 2008. In preparation for this, the registered provider and registered manager submitted information about the service by completing and returning an AQAA form. As part of the annual service review, surveys were sent to residents, staff, relatives and care managers. The information gathered at this time was also used to inform this key inspection. Comments from surveys and discussions with residents and others were mainly positive, for example, ‘good housekeeping, clean environment and good food’. Other anonymised comments are included throughout the report. At the end of this site visit, feedback was given to the registered manager on our findings, including recommendations that would be made in the key inspection report. Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The procedures and practices regarding the administration of medication have improved; medication is returned to the pharmacist at regular intervals, staff have had appropriate training and medication administration records are signed at the time that medication is administered to residents. Medication is now administered safely and this protects residents from harm. All staff have now been issued with a statement of terms and conditions of employment. Relatives are now included in the quality assurance process and are able to affect the way in which the home is operated. Staff now receive formal supervision six times per year. This gives them the opportunity to have a one to one meeting with their line manager to discuss any concerns or queries about individual residents or care practices in general. Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Manor House (The) DS0000066138.V367228.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 (The) DS0000066138.V367228.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): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met. EVIDENCE: At the random inspection on 28.9.06 we found that some people had been admitted to the home without a full assessment of their needs having taken place. On the day of this site visit we observed that all residents now have a full assessment of their needs undertaken prior to their admission. The registered manager confirmed that people are visited by staff at their current place of residency prior to their admission and that this is when the initial assessment of needs commences. We examined the care plan for a newly admitted resident and found that this included a pre-admission assessment Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 10 and a thorough care needs assessment, plus a moving and handling assessment that has been reviewed on a monthly basis. There is no photograph in place as yet for this resident and the registered manager was reminded that a photograph is needed to assist new staff with identifying residents and to assist the emergency services should someone go missing from the home. The other two care plans examined included a pre-admission assessment and a photograph of the resident. We noted that a community care assessment undertaken by care management (where people are funded by a local authority) had been used in conjunction with the care needs assessment to develop an individual plan of care for each resident. There is evidence that family members and health/social care professionals are consulted as part of the initial assessment process. There is evidence that people are only offered a place at the home if their assessment evidences that their needs can be met, and in some instances, a period of respite care is arranged to assist people in making a decision about permanent care. Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Health care needs are met in a way that respects a person’s privacy and dignity; this is recorded in and supported by well-maintained care planning documentation. EVIDENCE: We examined the care records for three residents; these included an individual care plan that was based on the care needs assessment undertaken by the home as well as information gathered from care management and family members. Care plans include risk assessments for moving and handling, environment, sight and hearing as well as those for more specific risks to the individual resident. There is evidence that residents and/or relatives are involved in the care planning process. Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 12 The registered manager told us that they are in the process of introducing new care planning documentation for all residents; some care plan records already include the new care plan format and other do not. Consistency will improve when the same documentation is used for all residents, and this should make things clearer for the staff that record information in care plans. Care plans record the areas where a person is able to self-care and detailed information about the level of assistance needed with personal care and continence care. Daily records are thorough and include information on food/fluid intake, a person’s sleep pattern and how and where they choose to spend their day. We noted that care plans are reviewed in-house on a monthly basis and are reviewed annually by care managers. We saw records on the day of the site visit that evidence that risk assessments are also reviewed and updated on a regular basis. Care plans include a record of a person’s nutritional requirements, such as a diabetic diet and any food allergies. There is a record of any visits from or contacts with health care professionals, including the reason for the visit, and detailed information is held regarding advice given by health care professionals following surgery or hospital visits. We observed that residents had been provided with pressure care equipment to assist with tissue viability, such as pressure care mattresses. A relative who was visiting the home on the day of the site visit told us that they are kept informed about health care issues concerning their relative. At the random inspection of 28.9.06 we found that some improvements needed to be made to the medication procedures and practices at the home. At this inspection staff were not signing medication administration records at the same time as they actually administered the medication, some staff had not had appropriate training and unused medication was not being returned to the pharmacist on a regular basis. There were also some gaps in recording on medication administration records. All of these areas of practice have now improved. Care plans include a record of a person’s current prescribed medication and there are risk assessments in place for any residents wishing to self medicate. These risk assessments are reviewed every four weeks; this is good practice. On the day of this site visit we observed the administration of medication by a trained carer; they prepared items needed for the medication round first, such as a jug of water, beakers and spoons. We noted that they signed medication administration records after they had seen the person take their medication, and that there were no gaps in recording. There is evidence that staff that administer medication have undertaken accredited training and there are sample signatures held for this group of staff to enable medication administration records to be checked for authenticity. In addition to this, the Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 13 member of staff that has administered medication on each occasion signs a record to evidence this; this is good practice. Medication is stored securely. Controlled drugs are stored in a metal cupboard that is attached to a wall in a separate office; the registered manager agreed to find out if this cabinet meets new guidelines on the storage of controlled drugs. We discussed relocating the storage cabinet for controlled drugs so that it is more accessible for staff. There are suitable recording facilities in place to be used when residents are prescribed controlled drugs. A care manager recorded in a survey, ‘medication is kept in a secure place and monitoring systems are in place’. We saw evidence that unused medication is returned to the pharmacist. We observed on the day of the site visit that residents are spoken to sensitively with regard to personal care, and that staff respect a person’s privacy by knocking on bedroom doors and by closing doors when people were using the toilet and bathroom. A GP told us in a survey, ‘staff always take residents to a private room when I am visiting them’. We observed that resident’s are treated as individuals, with consideration given to their personal relationships and particular lifestyle choices. Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to maintain their chosen lifestyle and to continue with their hobbies and interests, and visitors to the home are always made welcome. Residents tell us that meal provision at the home is good. EVIDENCE: Care plans include information about a person’s life history and previous lifestyle, including details of family and friends, their previous occupation and where they used to live. They also record information about a person’s preferred time to get up and go to bed and about personal likes and dislikes. Residents confirmed that they can get up and go to bed as a time chosen by them, and that this can vary from day to day, depending on their preference. We observed that residents are able to choose whether to sit in one of the communal areas of the home or in their own room. There are private areas of Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 15 the home where residents can meet with visitors to give them privacy. Visitors told us that they are able to visit the home at any time, and are always made welcome. When asked in a survey, ‘what do they do well?’ a relative responded, ‘looks after my mother very well and makes visitors very welcome. I think they are doing an excellent job’. We spoke to the activities coordinator who explained about the activities available to residents; it was noted that this includes one to one time being spent with those residents who prefer to remain in their room or to go out for a walk. Residents confirmed that there are activities that they are able to take part in, such as going out for a walk, going to a coffee morning in the village hall, bingo, quizzes, dominoes, entertainers and craft activities. Some people went out with relatives on the day of the site visit and we observed that the activities coordinator accompanied someone on a walk into the village. Some residents have had a telephone installed in their own room; they told us that this helps them to remain in contact with family and friends. The registered manager told us that the activities coordinator chairs the residents meetings, and asks them for suggestions about future activities and entertainers. There is a hog roast booked for August when family and friends will be invited to the home. Information about advocacy services is not displayed in the home; this would enable people to access these services without having to ask someone for the information and promotes privacy and independence. Discussion with the registered manager on the day of the site visit evidenced that appropriate advice and assistance is sought for residents when personal issues are identified. The AQAA completed by the registered manager records that residents are encouraged to bring personal items into the home, including small items of furniture; we observed this on the day of the site visit. Care plans record a person’s likes and dislikes regarding food. On the day of the site visit we observed that the menu was displayed on the notice board placed outside the dining room. This records a choice of meal at teatime but not at lunchtime. The registered manager told us that the cook has a record of peoples likes and dislikes, so prepares an alternative meal for someone if they do not like what is on the menu that day. Ideally, there should be a true choice of meal available at lunchtimes and residents should be made aware of this; the registered manager agreed to pursue this. We observed that people were offered fruit juice to have with their meal, and that ample drinks were made available during the day; some people had a jug of juice at the side of their chair whilst sitting in the lounge or in their bedroom. We observed that people were allowed to take their time when eating their meal and that staff offered appropriate assistance where needed. There is a separate dining room used by a small number of residents that need full assistance with eating their meal; we observed that each resident that needed one to one assistance received it. Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and others know how to use the complaints procedure and residents say that staff listen to them. Residents are protected from the risk of being abused by the training and skills of the staff group. EVIDENCE: There are appropriate complaints policies and procedures in place, and the complaints procedure plus a form for recording any complaints are displayed in the entrance hall. Residents and relatives told us that they know how to make a complaint and that they know who to speak to if they are dissatisfied with any aspect of care. They told us that they were confident that their complaints would be listened to and acted upon. Staff told us that they know how to advise someone if they wish to make a complaint; a member of staff told us in a survey, ‘I know to inform them of our complaints procedure and how it works. However, there have been many times when a relative or resident has not wanted to go down this route, when I have passed on their concerns to the manager, making a note in the resident’s care plan’. One complaint has been made to the CSCI since the last key inspection of the home and, as a result, we undertook a random inspection at the home. Another complaint has been recorded in the home’s complaints log and we observed that this had been dealt with appropriately. Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 17 There have been no recorded allegations or incidents of abuse at the home since the last key inspection. There are appropriate policies and procedures in place that are designed to safeguard vulnerable people from all types of abuse. On the day of this site visit we noted that the whistle blowing policy and information about various types of abuse were displayed on the staff notice board. Eleven staff (including ancillary staff) have undertaken training on safeguarding adults from abuse and all staff are due to undertake a refresher course in September 2008. In addition to this, the registered manager and three senior carers have attended the ‘Manager’s Awareness’ training course on safeguarding. The registered manager told us that safeguarding is one of the organisations mandatory training courses. A training course on dementia care is also planned for September 2008. Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained and well furnished and provides comfortable surroundings for residents. EVIDENCE: There is a maintenance book in place and this records the work undertaken by the maintenance person, who is employed to work 35 hours per week. There is no maintenance programme in place but planned maintenance and improvements are recorded in the AQAA that was completed by the registered manager prior to this inspection. We observed that the home is well maintained and there is evidence that equipment is replaced as necessary. Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 19 Communal areas of the home offer plenty of access to sunlight – some lounges include a conservatory area. Bedrooms also include access to sunlight and provide views of the surrounding countryside. Bedrooms are furnished and decorated to reflect the needs of the resident concerned, and many residents have brought small items of furniture from their own home. Furniture and fittings in communal and private areas of the home are domestic in nature and of good quality. Laundry facilities at the home are satisfactory. There is a domestic assistant and a cook on duty each day; this allows care staff to concentrate on personal care duties and reduces the risk of cross infection. No unpleasant odours were detected on the day of the site visit and we observed good hygiene practices being used by staff. One care manager recorded in a survey, ‘the home appears clean and does not smell’ and a relative recorded, ‘good housekeeping, clean environment and good food’. Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care staff are recruited in a safe way and receive induction and on-going training to ensure that they are qualified and skilled to care for the residents living at the home. EVIDENCE: We received information in September 2006 that staff had not been issued with a contract of employment and were expected to work excessive hours. A random inspection was undertaken and we found that staff had not been issued with a contract of employment by the new registered provider and that staff were not expected to work excessive hours. Staff records seen on the day of this site visit evidence that staff have now been issued with a statement of terms and conditions of employment. There is a satisfactory staff rota in place that records the role of each member of staff and the name of the senior person on ‘on call’ duty each weekend. Currently, the hours worked by the registered manager are not recorded on the staff rota and it was recommended that this should be the case, so that anyone wishing to speak to or meet with the manager could be told when they would next be available. Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 21 Some staff supervision records seen by the inspector on the day of this site visit indicated that staff have been working extra hours because the home is ‘short staffed’. We discussed this with the registered manager who said that, due to staff sickness, staff had been asked to work extra shifts so that staffing levels could be maintained. They are in the process of recruiting new staff to ease this situation. The home currently meets the requirement for 50 of care staff to have achieved the National Vocational Qualification (NVQ) Level 2 in Care - eleven care staff have completed NVQ Level 2 or 3 in Care and other staff are working towards this award. We examined the recruitment and selection records for two members of staff. These evidenced that a satisfactory application form that includes details of a person’s employment history, their previous experience and their training achievements is completed; we recommend that the application form should be amended to include a section where applicants are asked to declare any criminal convictions or cautions. This would enable the registered manager to confirm that a person has been honest when completing their application form when their CRB check arrives. In all instances, a Protection of Vulnerable Adults (POVA) first check and two written references had been obtained prior to the person commencing work at the home. The registered manager was reminded that, in normal circumstances, a satisfactory Criminal Records Bureau (CRB) check should be obtained prior to staff commencing work at the home, and that a POVA first check should only be used in exceptional circumstances. There is a training and development plan in place – this is very detailed and evidences that new employees have induction training when they are first in post and that this meets Skills for Care specifications. We saw that there is an individual training record for each member of staff that records the training that they have undertaken, and that training certificates are retained as evidence that staff have completed training courses. We saw information given to staff that informed them that they must attend mandatory training and that all staff would receive three paid days off per year to attend training sessions. Forthcoming training was advertised on the staff notice board. This included continence care, medication induction, nutrition and fire safety awareness. For the latter two courses, the organisation had identified the names of staff that needed to attend. We observed that the training provided by the organisation equips staff to meet the needs of the residents accommodated at the home. One member of staff recorded in a survey, ‘I have completed and passed my NVQ 3 which helped me understand the needs of our residents more fully’. Manor House (The) DS0000066138.V367228.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, 36 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, welfare and safety of residents and others are protected by the systems in place. EVIDENCE: The registered manager is experienced and qualified to manage the care home; she has completed NVQ Level 4 in Care and the NVQ 4 Registered Manager’s Award, and told us that she is now continuing with her training by undertaking NVQ Level 5 in Management. The registered manager keeps her practice up to date by using the CSCI Professional web site and by reading care journals. She has recently been meeting with other managers in the organisation to discuss consistency; policies, procedures, care plans etc. will be Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 23 updated as a result. The registered manager attends in-house training with the staff group and is due to undertake training on nutrition and palliative care shortly. We observed on the day of the site visit that staff and the manager worked well as a team. However, a relative told us in a survey, ‘communication channels between residents and relatives could improve and management of care staff should be in a professional manner rather then as “mates”’. The home has achieved the Quality Development Scheme (QDS) Parts 1 and 2; this is a quality scheme operated by the local authority. The quality assurance systems in place at the home enable residents and others to affect the way in which the home is operated. Surveys were distributed to residents and relatives in May 2007 and the results of these were analysed and then displayed on the notice board. Surveys have been sent out again this year and the registered manager is waiting for these to be returned so that the results can be analysed and actioned. Residents meetings are held every two months and staff meetings are held every 2 – 3 months. One relatives meeting was held but the registered manager told us that these meetings are now usually held on a one to one basis. Relatives are invited to events held at the home, for example, the forthcoming hog roast. The registered manager was reminded that a copy of collated quality assurance information should be forwarded to the CSCI. We saw evidence on the day of the site visit that staff now have regular supervision sessions, an annual appraisal and the opportunity to discuss their views at staff meetings. Staff told us that they feel comfortable in expressing their views and that these are listened to. Quality checks are undertaken by the responsible individual on a monthly basis and the resulting reports are available for inspection. We examined the records for monies held on behalf of residents and crosschecked these with actual monies held - both were found to be accurate. Receipts are obtained for any purchases made on behalf of residents. We recommend that a receipt be given to relatives when they hand money to staff for residents for safekeeping and when money is handed to residents, to protect all parties concerned. We examined health and safety documentation for appliances, equipment and services at the home. These were all up to date, including the fire alarm test, portable equipment testing, the gas safety inspection and the servicing of hoists. There is a very detailed fire risk assessment in place and this is reviewed annually. There is an accident book in use and the information recorded in the book is cross-referenced to a person’s care plan. We noted that staff sometimes record an update on the resident’s condition, such as ‘X has been fine all day – no bruising as yet’. This is good practice. Accidents are analysed by the Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 24 organisation and this assists the manager to recognise any patterns in falls or accidents and to take appropriate action; this is good practice. The CSCI are now being informed of accidents and incidents at the home via notification under Regulation 37 of the Care Homes Regulations 2001. There are risk assessments in place to record safe working practices and this information is updated appropriately. Staff undertake training on health and safety topics; this training is mandatory and is updated on a regular basis. The registered manager or a senior carer completes a health and safety checklist every month to monitor the health and safety systems in place. Manor House (The) DS0000066138.V367228.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 4 Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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. 4. 5. 6. 7. Refer to Standard OP3 Good Practice Recommendations There should be a photograph in place for new residents to assist staff with identification and to help the emergency services should someone go missing from the home. Information about advocacy services should be readily available in the home for residents and others. There should be a true choice of meal at lunchtimes and residents should be made aware of this. The hours worked by the registered manager should be recorded on the staff rota so that staff are able to tell enquirers when she is next on duty. The current application form should be amended to ask applicants to record any criminal convictions or cautions. A POVA first check should only be used in exceptional circumstances, not routinely. Receipts should be given to relatives when they hand money over for safekeeping, and when money is handed to residents, to protect all parties concerned. OP14 OP15 OP27 OP29 OP29 OP35 Manor House (The) DS0000066138.V367228.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 (The) DS0000066138.V367228.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. 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!