Care Home: Manor Park Nursing Home

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What the care home does well Manor Park provides a safe and homely environment for people to live in. The staff and the people that use the service appear to have very good relationships with each other and the atmosphere between them is relaxed.This helps the people that use the service to feel very settled and this means that they can rely on the staff for any support that they may need. Individuals are provided with meals that they choose and like, however they are encouraged to follow a healthy diet including lots of fresh fruit and vegetables to try and maintain their health. The health needs of the people living in the home are well met and staff are provided with a good amount of training to make sure that they understand the needs of the people that they are caring for and that they can do their jobs well. The manager is well qualified and makes regular checks to ensure that the service is meeting the needs of the people living and working in the home. The home is well managed and systems are in place to protect the health and safety of the people who live there and the staff. What has improved since the last inspection? The homes statement of purpose and service user guide have been made easier to read and include all of the information about the home and the services that it provides. The daily records that are made in the home have improved and include more information. Staff are provided with supervision on a more regular basis to make sure that they have the knowledge and skills to care for the people that use the service. CARE HOMES FOR OLDER PEOPLE Manor Park Nursing Home Leeds Road Cutsyke Castleford West Yorkshire WF10 5HA Lead Inspector Stephen Robertshaw Key Unannounced Inspection 5th August 2008 09:00 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 Park Nursing Home DS0000068595.V369828.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 Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Park Nursing Home Address Leeds Road Cutsyke Castleford West Yorkshire WF10 5HA 01977 604242 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) manorpark@schealthcare.co.uk CC Care Ltd Care Home 75 Category(ies) of Dementia - over 65 years of age (75), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (75), Old age, not falling within any other category (75), Physical disability over 65 years of age (75) Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th April 2007 Brief Description of the Service: Manor Park is a two-storey purpose built care home that provides accommodation for 75 older people requiring either residential care, general nursing care and/or dementia care. Qualified nurses are employed at the home and a good number of care staff are trained to National Vocational Qualification standards (NVQ Level 2 or above). The home employs an activities organiser. The home, which is situated off the main road in Cutsyke Castleford has pleasant gardens and is situated close to local shops. There are local public transport links to the town of Castleford and access by private transport to the motorway network. The home has three distinct units each with lounges and dining areas. Quiet rooms provide space for service users and visitors to sit and relax away from main lounges or as a change of environment from their own bedrooms. Fees for the service can be obtained through the management. Additional charges include hairdressing, private chiropody, newspapers and some selected activities. Information about the home and the last inspection record and the services provided are available from the home in the statement of purpose and service user’s guide. These can be obtained by contacting the home. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken Manor Park Nursing Home DS0000068595.V369828.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. The Commission made a site visit to the service on the 5th of August 2008. The visit was unannounced and we were at the home for approximately seven hours. We have used some of the evidence gathered on this day to write this report. Other information was gathered through case tracking seven of the people that live at the home. This means that we looked at all of the information held about their care in the home, and spoke with them, or their families and friends and the people that were responsible for paying b for their fees. We also spoke with two professional visitors to the home and we spoke with six visitors on the day of the site visit. The Commission also looked at the staff records in the home. This showed how they had been employed and what training they had completed to make sure that they could safely look after the people that are living at the home. We also walked around the building to make sure that the environment was safe and provided a homely atmosphere. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: Manor Park provides a safe and homely environment for people to live in. The staff and the people that use the service appear to have very good relationships with each other and the atmosphere between them is relaxed. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 6 This helps the people that use the service to feel very settled and this means that they can rely on the staff for any support that they may need. Individuals are provided with meals that they choose and like, however they are encouraged to follow a healthy diet including lots of fresh fruit and vegetables to try and maintain their health. The health needs of the people living in the home are well met and staff are provided with a good amount of training to make sure that they understand the needs of the people that they are caring for and that they can do their jobs well. The manager is well qualified and makes regular checks to ensure that the service is meeting the needs of the people living and working in the home. The home is well managed and systems are in place to protect the health and safety of the people who live there and the staff. What has improved since the last inspection? 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 Park Nursing Home DS0000068595.V369828.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 Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the people that use the home have an assessment of their needs before they are admitted there to make sure that the staff will be able to support their needs. EVIDENCE: The home has a statement of purpose and service user guide. These were observed by the Commission and were seen to be very detailed and included the aims and objectives of the service, it’s philosophy of care, and the services and facilities that are provided. These documents provide people that may wish to use the service all of the information that could help them to be able to make a decision if they want to move into the home or not. The proprietor information and manager information had been updated since the last inspection. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 9 People that are admitted to the home receive a community care assessment, which has been completed by the person’s social worker. This assessment determines the level of care the person requires. The home also carry out their own pre-admission assessments to make sure that the service has the skills and knowledge to be able to safely provide care to the prospective new residents. The Commission observed the assessments for seven of the people that use the service. These had all been completed before they had made a decision to live at the home. We spoke with several people and they all confirmed that they had received an assessment before they moved to the home. One person said ‘the manager came to see me at the hospital’, and another said that staff from the home ‘’visited me in my house and told me about the home’. Both the local authority and pre-admission assessments were quite basic in the information that they provided. This may make if difficult to identify the individual needs of the people that are requiring support. Although the home cannot do much to improve the quality of individuals community care assessments (local authority assessment of need) their own pre-admission assessments should include more personal information in relation to individual needs and how they should be addressed by the home. For example if a person needs support with their mobility needs, how do they prefer these needs to be met. People that use the service also told the Commission that they were given the opportunity to have trial visits to the home to help them to decide if it would be ‘right’ for them. One person said ‘I came for a couple of days to have a look around’. The service does not provide intermediate care and therefore National Minimum Standard 6 is not applicable. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that people that use the service can expect all of their personal and healthcare needs met through the services provided through the home and their professional partners in the community. EVIDENCE: We case tracked seven of the people that use the service. This means that we looked at all of the documents relating to their care in the home, speaking with relatives and outside professionals that also offer them support. The care plans that were observed by us supported all of the needs that had been identified in individual’s assessments of need. The care plans also informed the staff of the support that people needed to maintain their health and social care needs. Risk assessments were also seen to be on position to support peoples care plans in areas that included nutrition, moving and handling and skin integrity. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 11 A visiting professional stated to the Commission that if they left treatment plans at the service for any individual they were ‘confident’ that they would be supported by the homes staff. Individuals care files also identified when they had received treatments or had appointment with healthcare professionals that are based in the community. The manager of the service (not yet registered with the Commission) confirmed that qualified nursing staff and senior care staff are responsible for the administration of medication to people that use the service. Training records and interviews with staff supported that all people that administer prescribed medication in the home have received appropriate training to support the health and safety of the people that received medication. People that use the service are encouraged to self medicate if they are able to. A risk assessment would be completed in this instant to asses if the person would be safe to take their own medication. The staff would then support the person in maintaining their medication and to keep the appropriate records. The medication was observed being given out and the medication room and records were also inspected. All appropriate legislation and good practice guidelines had been followed. The staff administering the medication were very professional and showed dignity and respect to the individuals that were receiving their medication. One person said ‘the staff give me my tablets, I couldn’t remember or do it for myself’. The records for all of the individuals that were case tracked included their GP signatures for any home remedies that could be administered. The pharmacy that provides medication to the home audits their medication every six months to make sure that the stocks in the home are appropriately stored and accounted for. They have also recently supplied the home with two new fridges and two new medication trolleys for their medication rooms. Controlled medications in the home were also looked at and they were all appropriately stored, recorded and accounted for. People that use the service had individual Medication Administration Record sheets. This had a front sheet that included the individual’s photograph to make sure that the right person was matched up with their medication. If any additional medications had been added to the record sheets two members of staff had signed to confirm when they had been introduced. Since the last inspection the sluice has been removed from the medication room. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 12 Throughout our time in the home on the day of the site visit, our observations, discussions with people that use the service, with visitors and staff working at the home confirmed the evidence that peoples dignity and respect is upheld at all times. One person said ‘when I see my family, or the nurse I am always seen by myself in private’. Manor Park Nursing Home DS0000068595.V369828.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the people that use the service can be confident that their interests and hobbies can continue once that they have been admitted to the home. EVIDENCE: The home employs a full time activities co-ordinator. They arrange and supervise the social activities within the home. Social activities are planned in the home on a weekly rolling pattern. The current activities are advertised in the reception area of the home and smaller notices are available on each unit. There is an activities room were service users are able to join in with making crafts and artwork. Larger activities such as movement to music take place in one of the communal lounges and people from other units are able to join in. The home provides a range of activities for people to choose from. Care staff said they help the activity co-ordinator by taking part in the organised activities. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 14 People spoken to by the Commission said that their families and friends were always welcome at the home at any reasonable time. One visitor stated ‘although you can see that the staff are very busy, they always have a smile on their faces and time for you’. Another said ‘we are always made welcome here, the staff are very friendly and caring’. People are supported to develop their own individual lifestyles whilst at the home and are encouraged to make choices for themselves throughout their daily lives. The manager stated that a four-week menu cycle had been developed for the home and there are two choices of main meal on offer at each mealtime. The menus observed by the Commission confirmed this. People can have their meals in the dining room or take them to their own room if they choose to do so. Direct observation supported the evidence that the meals in the home are well presented and that a choice is available to individuals. The catering manager stated that if people do not want anything that is on the menu them something of their choice would be provided for them. He also stated that the homes menus are influenced through the homes quality assurance programme and speaking to the people that live at the home to find out what they like to eat. People spoken to by the Commission very positive about the quality of the meals that are provided for them. One person said ‘the foods better than being in a hotel’. Manor Park Nursing Home DS0000068595.V369828.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that people that use the service are protected from potential abuse and they have a clear complaints procedure to follow if they have any concerns to raise in relation to the service. EVIDENCE: The home has a clear complaints policy and procedure. A copy of this is available in the reception area of the home and is also included in the service users guide to the home. Individuals spoken to by the Commission said if they had any complaints they knew who to talk to about them, and appeared to be confident that they would be dealt with appropriately. One person said ‘the home is good, I don’t have any complaints but if I did I would let them know about them’. Since the last inspection no formal complaints had been made in relation to the service at the service itself or directly to the Commission. The manager said that any complaints that could be received would be investigated in an appropriate manner. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 16 The manager of the home stated that it had been difficult to establish formal safeguarding adults training for the staff, however she confirmed that a different external training agency had been approached to deliver safeguarding training to the staff group. Staff training records supported that new staff members have attended safeguarding training as part of their induction. Other training records showed that staff had received training in safeguarding through National Vocational Qualification (NVQ) training and training provided through the local authority. The manager confirmed that all of the staff would receive safeguarding training on a regular basis to make sure that the staff can support the needs of the people that they are caring for and keep them safe. All of the staff interviewed by the Commission had a clear understanding of safeguarding adult’s issues and their responsibilities of reporting any concerns or allegations of abuse. Since the last inspection there had been five referrals made to the local safeguarding adults team. The home was prompt in making the referrals and were honest and open in the investigations. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 17 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, 20, 21, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that people that use the service live in a pleasant and homely environment. EVIDENCE: We made a tour of the premises as part of the site visit. The home layout was fit for its intended purpose, was accessible and was well maintained. The communal areas were well decorated and people stated that they were happy with how the home was presented. One person said ‘its clean and tidy and its always kept this way’. The lighting and heating used at the home were domestic in character. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 18 Several people invited us to look at their individual bedrooms and all of these had been decorated and furnished to their own tastes and preferences. This included small items of personal furniture, pictures and ornaments. One person stated that ‘I have all of my things here, it makes it more comfortable and like home’. Staff were observed visiting people in their rooms. At all times they knocked on the doors and asked permission to enter before going in to the rooms. The toilets and bathroom areas of the home are kept clean and free from any offensive odours. One concern on the day of the site visit was that some linen towels had been left in the bathroom accessible to anyone that entered the room. This could lead to infection control problems. When this was pointed out to the manger the towels were immediately removed and the area was made safe and met the requirements of the homes infection control policies and procedures. There are a number of communal bathrooms fitted with specialist hoists and baths to enable people who have mobility problems to bath safely. Toilet number 8 was in need of redecoration and bathroom 8 also required some attention. Since the past inspection of the service the unit in which people with enduring mental health problems live had been redecorated and new corridor and lounge carpets had been fitted. This has improved the environment in for the people to live in. Tactile pictures, which service users can touch and enjoy, had been placed around the unit. As some of these included neckties and scarves we advised the manager of the service to make sure that they had all been risk assessed considering the needs of the people living in the unit. The manager and staff at the home have been trying to improve the environment for all of the people that use the service. Some walls have had murals painted on them, however the manager said that these were going to be replaced, as they had not had the positive effect that they had wished for. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the staff working at the home have the knowledge and skills to be able to safely care for the people that are in their care. EVIDENCE: The Commission looked at the work rosters for the home. This showed that there are adequate numbers of staff available at all times. We also looked at three staff personal and training files. These supported the evidence that appropriate safety vetting was carried out before the staff were employed to work with the people that use the service. This included safety checks with the Criminal Records Bureau (CRB) and references had been obtained from previous employers and personal contacts. This ensures that people who appear on the adult protection register are not employed by the home. Discussions with the manager of the service and interviews with staff supported the evidence that new staff undertake induction training within six weeks of the joining the home. Foundation training is then provided within the first six months of service. This training makes sure that any new member of staff has the information and knowledge to safely enable them to meet the needs of the people living in the home. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 20 Staff training records showed that they are provided with all of the required mandatory training and specialist training that they require to support the needs of the people in their care. Approximately 67 of the care staff have achieved a minimum of NVQ 2 in care (National Vocational Qualification). Staff are also provided with the opportunity to complete NVQ 3 in care dependent on their position and responsibilities. Evidence was seen in training records checked that some staff have received training in such things as moving and handling, medication, infection control, fire safety and adult safeguarding, although the need to review safeguarding training is detailed in the complaints and protection section Staff are also provided with formal structured supervision on a very regular basis. This helps to make sure that they understand their roles and responsibilities and those of their colleagues and to identify any personal or group training needs. They are also provided with two appraisals a year to make sure that they are confident and are competent in their roles. Individuals that use the service were very positive in relation to the staff group. One person said ‘the staff are always very busy, but they always have time for you’, another person said ‘they are good and help me to do things that I cant do for myself’. Staff in the dementia unit were observed working with the people that live in this area of the home. The staff were very patient and supportive of the individuals and provided the individuals with a high level of dignity and respect. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the management of the service are able to safely support the needs of the people that use the service and to support the staff that work in the home. EVIDENCE: The current manager of the home has been in position since March 2007 and has not been recognised by the Commission as the Registered Manager of the service. The manager is a qualified Registered General Nurse and has completed an NVQ 4 in care. She also has qualifications in Tissue Viability and Continence Care. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 22 Care and nursing staff and people that use the service were all very positive in relation to the manager of the home and stated that she was very open and approachable. One visitor to the home said ‘the manager is very friendly and helpful. She always lets us know when there are any changes in …health’. The manager could not demonstrate that the home has an effective quality assurance monitoring system in position. It is important to establish this system to make sure that other people have an opportunity to say how they think that the service is working and to help to identify any areas of service delivery that need improving. The management of the home do create a newsletter to show people what is happening at the home and in the community. This information could be used to support the homes quality assurance programme. People that use the service are encouraged to be responsible for their own finances for as long as they can safely do so for themselves. When they are not advocates and other supports are looked for to help the individuals with their finances. Our observations of staff supervision records show that they are supervised every month, and at each supervision session they have a ‘topic’ of the month to discuss with their manager. This helps to make sure that the staff have all of the skills and knowledge to safely care for the people that are living at the home. The management of the home ensure as far as it is practicable the health, safety and welfare of the people that work and live at the home. All of the home maintenance records were observed and were seen to be up to date and had been accurately recorded. Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 23 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 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 2 3 3 3 3 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 2 X 2 X 3 4 X 3 Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 24 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 OP31 Regulation 8,(1),(2), 9,(!),(2) Requirement The registered person must make sure that the homes manager is registered with the Commission. This is a legal requirement to support the professional capacity of the manager. The registered person must develop an effective quality assurance and monitoring system that identifies how other people view the services provided by the home. Timescale for action 30/10/08 2. OP33 24,(1),(2) and (3) 31/12/08 Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations The management of the service should make sure that the homes pre-admission assessments are clear and explicit, they should also attempt to sure that assessments received from placing authorities and also clear and explicit and detail the level of support and care that individuals would require. This would help to make sure that only people whose needs can be met through the services provided by the home are admitted. The registered person should make sure that when any records in the home are made they are fully signed and dated this includes individual weight records. Abbreviations should also not be included in the records and post it notes should be recorded more formally in the care file records as post it notes can become lost or attached to other irrespective information. This will help to identify who creates any of the records and will support the health and safety of the people that are using the services. The registered person should make sure that the tactile equipment in the dementia unit is fully risk assessed to support the health and safety of the people that live in this area of the home. The registered person should make sure that all communal toilet and bathroom areas are maintained clear of any objects that may have a negative effect the health and safety of the people that use the service and work at the home. This includes following the homes infection control policies and procedures. The registered person should make sure that bathroom number 8 and toilet number 8 are redecorated to provide a more homely and healthy environment for the people that access these areas. 2. OP8 3. OP12 4. OP21 OP26 5. OP21 Manor Park Nursing Home DS0000068595.V369828.R01.S.doc Version 5.2 Page 26 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 Park Nursing Home DS0000068595.V369828.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. 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