Care Home: Park Manor

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What the care home does well Park Manor provides a homely, relaxed and comfortable environment with a welcoming and friendly atmosphere. The home and grounds are also attractive and well maintained. Residents say that staff are kind and caring and that their privacy and dignity is respected at all times. Residents are encouraged to make choices about how they live their lives and the home assists in providing access to social, cultural and recreational activities. A wide programme of events has been created. Residents are encouraged to maintain their links with family and friends and visitors to Park Manor are made welcome. People are positive about the food at Park Manor. Food is well presented and staff are available to assist residents if help is required. The complaints and adult protection procedures ensure that residents and their representatives well-being and comfort is important to the home and that any concerns raised will be properly investigated and resolved. Sufficient numbers of staff are on duty throughout the day and night to be able to meet the care needs of people. The home is meeting the Department of Health target of having 50% of their care staff with National Vocational Qualifications in care at level 2 or equivalent. Recruitment procedures are good ensuring that staff are suitable to work in the home and residents are well protected. Induction and staff training are good which means that staff are better equipped to meet residents needs. Management is good. Financial procedures within the home also ensure that residents` interests are protected. What has improved since the last inspection? Pre-admission assessments are now more detailed and provide evidence that each persons needs are understood and can be met by the home. All residents now have a plan of care from the day of admission which sets out in detail the actions that must be taken by staff to ensure that all aspects of their health, personal and social care needs are met. Care plans are now reviewed regularly and reflect any changes in needs or care.Nutritional assessments are being carried out and regularly reviewed however it is recommended a suitable nutritional assessment tool is also implemented. Scales, which can weigh all residents, are also now available. Staffing rotas now show the surnames of all staff. The practice of operating 14 hour shifts has been reviewed and it is clear who is in charge of the home. Evidence that qualifications obtained abroad equivalent to UK requirements, are now obtained. The content and duration of staff training in fire safety is now recorded. Fire drills are now held without prior warning to the staff to enable management to assess the adequacy of training. Cleaning materials are stored securely and not left unattended. What the care home could do better: A suitable nutritional tool should be implemented to help with the nutritional assessments of all residents. Medication administration, recording and storage must be safe and accurate to minimise any risks to residents, including countersigning handwritten entries to the Medication Administration Records and clear audit trails, including opening dates for short lived medications. Soap dispensers for hand washing should be affixed to the wall in the laundry area as good practice for infection control. The details of any verbal references taken for a potential staff member should be fully recorded in that staff members file. The quality assurance process should be further improved, including the use of various audits. CARE HOMES FOR OLDER PEOPLE Park Manor 8 St Aldhelms Road Branksome Park Poole Dorset BH13 6BS Lead Inspector Jo Pasker Unannounced Inspection 15 July 2008 09:30 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 Park Manor DS0000004055.V363382.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. Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Manor Address 8 St Aldhelms Road Branksome Park Poole Dorset BH13 6BS 01202 764071 01202 765505 No email 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 Manor Limited Mrs Janice Scanlon Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2007 Brief Description of the Service: Park Manor is situated in a residential area of Branksome Park. The local area has a range of shops, a post office, library, public house and other leisure facilities. Public transport is accessible with bus routes and a train station nearby. Park Manor is a large house built in the late nineteenth century. Many of the original features are incorporated into the current building, which has been extended and adapted to accommodate older people. The home has substantial grounds, surrounded by mature trees and shrubs. The gardens are kept to a high standard. Accommodation at Park Manor consists of single and double rooms, all with ensuite facilities; a passenger lift provides access to the first and second floor. Spacious communal areas are available and include two sitting rooms, a large dining room and a smaller dining area. A large Victorian conservatory overlooks the well-maintained gardens. There is also a small interview room which is available to residents should they wish to receive visitors in private in an area other than their bedroom. The back of the house has been extended to provide 12 self contained apartments, each with its own front door and which include a sitting room, bedroom, bathroom with toilet and a small kitchen area. A lift operates on all 3 floors of the apartment block. The care, catering and laundry services of the main house also service the apartment block. At the time of inspection weekly fees ranged from £575 to £1000. Additional charges are made for hairdressing, chiropody, newspapers, toiletries, transport and telephone. See the following website for further guidance on fees and contracts: www.oft.gov.uk (Value for Money and Fair Terms in Contracts). Park Manor DS0000004055.V363382.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 unannounced key inspection was carried out over approximately 6 hours on the 15 and 16 July 2008. This was a statutory inspection and was carried out to ensure that the residents who are living at Park Manor are safe and properly cared for. The Registered Manager, Mrs Jan Scanlon, was on hand throughout to aid the inspection process. Information gathered for this report came from several sources including: • Reports made to the Commission for Social Care Inspection by the home. • The annual quality assurance assessment (AQAA) completed by the home. • 5 questionnaires completed by residents and 1 by a health professional. • Tour of the premises. • Review of a variety of documentation including care records, staff records, maintenance records, policies and procedures. • Discussion with residents and staff. During the course of the inspection 4 residents, 1 visitor and 3 members of staff were spoken with and asked their views on the service provided at the home. Comments received through the questionnaires and inspection included: ‘A very pleasant environment for clients’ ‘I could not have wished for better care for her’ ‘Management and staff are excellent with my mother’ ‘I am very happy with the standard of care that is provided’. What the service does well: Park Manor provides a homely, relaxed and comfortable environment with a welcoming and friendly atmosphere. The home and grounds are also attractive and well maintained. Residents say that staff are kind and caring and that their privacy and dignity is respected at all times. Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 6 Residents are encouraged to make choices about how they live their lives and the home assists in providing access to social, cultural and recreational activities. A wide programme of events has been created. Residents are encouraged to maintain their links with family and friends and visitors to Park Manor are made welcome. People are positive about the food at Park Manor. Food is well presented and staff are available to assist residents if help is required. The complaints and adult protection procedures ensure that residents and their representatives well-being and comfort is important to the home and that any concerns raised will be properly investigated and resolved. Sufficient numbers of staff are on duty throughout the day and night to be able to meet the care needs of people. The home is meeting the Department of Health target of having 50 of their care staff with National Vocational Qualifications in care at level 2 or equivalent. Recruitment procedures are good ensuring that staff are suitable to work in the home and residents are well protected. Induction and staff training are good which means that staff are better equipped to meet residents needs. Management is good. Financial procedures within the home also ensure that residents’ interests are protected. What has improved since the last inspection? Pre-admission assessments are now more detailed and provide evidence that each persons needs are understood and can be met by the home. All residents now have a plan of care from the day of admission which sets out in detail the actions that must be taken by staff to ensure that all aspects of their health, personal and social care needs are met. Care plans are now reviewed regularly and reflect any changes in needs or care. Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 7 Nutritional assessments are being carried out and regularly reviewed however it is recommended a suitable nutritional assessment tool is also implemented. Scales, which can weigh all residents, are also now available. Staffing rotas now show the surnames of all staff. The practice of operating 14 hour shifts has been reviewed and it is clear who is in charge of the home. Evidence that qualifications obtained abroad equivalent to UK requirements, are now obtained. The content and duration of staff training in fire safety is now recorded. Fire drills are now held without prior warning to the staff to enable management to assess the adequacy of training. Cleaning materials are stored securely and not left unattended. 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. Park Manor DS0000004055.V363382.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 Park Manor DS0000004055.V363382.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 does not apply to this home). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admissions procedure enables prospective residents (and/or those acting on their behalf), to make informed decisions about admission to the home and ensures that only residents whose needs can be met by the home are offered places there. EVIDENCE: The pre admission documentation for 1 resident was inspected. This showed that the home has a good procedure in place and ensures that a full assessment of needs was undertaken with the prospective resident, family and hospital staff prior to them moving into the home. Sufficient information was obtained so that a comprehensive care plan could be drawn up for staff to follow and ensure that individual needs are met. Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 10 Of the 5 residents who responded to the surveys sent out 4 replied that they had received a contract, 1 did not respond and all replied that they had received enough information about the home, before they moved in, to help them decide if it was the right place for them. Park Manor DS0000004055.V363382.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. This judgement has been made using available evidence including a visit to this service. Detailed care plans are now available for individual residents and accurately reflect the practice that is carried out, in meeting people’s needs and preferences. The health needs of the residents are met with evidence of good support from community health professionals and residents are treated with dignity ensuring that that their rights and privacy are upheld. The standards for medicine handling and recording are generally well managed however some minor shortfalls must be addressed to ensure residents are safeguarded from any risk. EVIDENCE: Since the last inspection improvements have been made in care planning and all the relevant pre admission assessments and information were referred to. The care files for 4 residents were reviewed and contained a variety of Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 12 assessments. The information from the assessments was used to formulate a plan of care for each resident and they contained sufficient detail so that staff could give the appropriate care. There was evidence that some care plans had been discussed with the resident or their representative as the relevant person had signed them or it had been documented if a resident had refused to sign them and why. The home have implemented a new falls risk assessment and pressure area assessment and recording system since the last inspection and improvements have been made in nutritional screening. However, this will be further improved by the introduction of an appropriate nutritional screening tool. It was clear from discussions with staff, residents and visitors that there is access to the health services needed. There was evidence to show that residents get support from General Practitioners, the district nurse and chiropodist. Appropriate referrals are also made to specialist services, such as speech and language therapy, when needed. The medications policies and procedures were reviewed. Medicines were stored securely. However there were shortfalls in recording which included: • Handwritten prescriptions were not always signed and dated. • Some medications-eye drops- had no record of their date of opening. Examination of records indicated that generally medicines are properly administered in accordance with the prescriber’s instructions. All staff responsible for the administration of medication were appropriately trained to do so. Residents appeared well cared for and people spoken with confirmed this, commenting that ‘The staff are very good’. They also confirmed that staff treated them with respect and were observed to knock on doors and address people by their preferred name. Park Manor DS0000004055.V363382.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 & 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a wide range of activities and events for residents and they are encouraged to maintain contact with the local community. Friends and relatives are also warmly welcomed by the home. Both relatives and staff members assist residents to make choices about their daily lives and the meals offered provide choice and variety ensuring that people receive a wholesome diet. EVIDENCE: The home has a monthly social activities programme, which includes oversized scrabble games, music and movement and church services. Individual interests and employment and hobbies, past and present, are discussed and documented as part of the pre admission procedure and to help provide a more personalised approach to the residents’ daily lives. Park Manor has several communal areas where activities can take place, including a lounge and 2 dining rooms, 1 with a television. Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 14 Some residents of the home have also started to care for a stray cat, which they get great pleasure from. Trips out to local places of interest are also a regular feature, as the home owns a minibus and visits planned were to Hengistbury Head, a walk along the river in Christchurch and bowling. Residents and visitors spoken with confirmed that visitors are made welcome at any time and that they are able to spend time privately in residents’ rooms if wished. One visitor said they were very happy with the care the home was providing to their friend and said that it was a very welcoming place. Visitors are also welcome to stay for meals and Park Manor have a guest room for visitors to stay in if they are travelling from a long distance. All rooms seen contained personal pictures, photographs and items of furniture. Lunch on the day was a choice of Irish stew and dumplings or poached haddock and cheese sauce. Residents were seen to be enjoying their meal and confirmed that they could choose whether to eat in their room or the dining room. Those spoken with about the food said, ‘It’s lovely-as good as I could cook!’ The kitchen appeared clean and tidy, with a large well kept fridge, freezer and dry area store. Plenty of food was available including fresh fruit and vegetables. The Environmental Health Department (EHO) last visited in February 2008 and passed the kitchen as meeting EHO standards. Park Manor DS0000004055.V363382.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 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good complaints system, which ensures that complaints are managed properly and residents and relatives can be sure that their concerns will be listened to and acted upon. Policies and practice, in order to safeguard residents from potential abuse and harm, are also promoted. EVIDENCE: Residents said that they knew how to complain and felt confident that if they had concerns or complaints they will be listened to and taken seriously. Only 1 complaint had been received by the home since the last inspection and records showed that this had been well investigated and what the outcomes had been. Health care professionals also indicated that the home had always responded appropriately if concerns had ever been raised. The home has policies and procedures for the protection of residents from abuse or neglect and provides all staff with training in the understanding of abuse and their role in protecting residents from abuse in its many forms, including neglect. Staff spoken with confirmed that they had received training and demonstrated a clear understanding of the home’s procedures. Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The standard of the environment at Park Manor is excellent providing residents with an attractive, homely and safe place to live. EVIDENCE: The home has a programme of routine maintenance. Records show the equipment and facilities with the home are regularly serviced. Since the last inspection several areas in the home have been upgraded and the garden has been landscaped with a fountain and sun awnings fitted to the apartments, at the request of residents. The owners of the home are also replacing the windows in the original building with double glazed sash windows in keeping with the property and are considering how best to upgrade the heating system with the least disruption to the residents. Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 17 Staff are employed specifically for cleaning the home and all people responding to the residents’ surveys thought that the home was ‘always’ fresh and clean. Good infection control procedures were seen to be in use with the staff observed to be using gloves correctly when needed and most have received some training in this area. No soap dispenser was seen available in the medicine room to enable staff to wash their hands. However, during discussion with the manager it was clear that the home had one but needed to affix it to the wall to meet infection control standards. Adequate facilities were available to manage the home’s washing and a housekeeper and full time laundry person are also employed. Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient care staff are employed and receive the training and support needed, so that they can give a good standard of care to the residents living at Park Manor. Good recruitment procedures are in place to protect residents from the risk of unsuitable staff working at the home, however best practice is not always implemented. EVIDENCE: Staff rotas demonstrated that there were sufficient staff on duty to meet the needs of the residents and this was observed in practice, during the inspection. Residents spoken with confirmed that staff were available when they needed them and from surveys returned, 3 people said that this was ‘always’ the case and 2 said ‘usually’. The home has an ongoing training programme, which includes NVQ level 2 and 3 in care and at the time of inspection more than 50 of the care staff hold the minimum of a level 2 award in care. A further 2 members of staff were working towards their level 3 award. Three staff recruitment files were reviewed. All files contained the information and documents required, including POVA first and enhanced Criminal Record Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 19 Bureau checks. However, verbal references recorded as having taken place in 1 staff file, had not been fully documented with the details of the conversation. Training files demonstrated that staff were receiving induction training. The majority of staff have received all mandatory training required, including infection control, moving and handling and fire training. Some staff have also recently begun to undertake training in dementia care. Further information on available training can be accessed through the following websites: www.picbdp.co.uk www.skillsforcare.org.uk Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, with good quality assurance systems being developed and the daily management and running of the home centres around the best interests of the residents and their finances. The welfare of all people is well promoted and protected, ensuring that risks to health and safety are minimised. EVIDENCE: The registered manager of Park Manor is Mrs Jan Scanlon who is suitably experienced and qualified to manage the home, holding an NVQ level 4 in management and the Registered Managers Award. Staff and residents spoken with confirmed that they felt comfortable about approaching the manager with Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 21 any issues and it was observed that Mrs Scanlon spoke to everyone during a tour of the premises and clearly had a good rapport with all people. The home is currently without a deputy manager but is actively recruiting for a suitable person to take up this post. The home has submitted an annual quality assurance assessment (AQAA) to the Commission, detailing how they currently meet Care Standards and how they plan to improve. Updated annual questionnaires for residents, families and other stakeholders are completed to gain their opinions on the running of the home. There is an annual development plan in place and the home plan to implement the use of more audit tools to further improve their quality assurance system. Residents either deal with their own finances or have a representative to do so. The home will hold a small amount of money for people. Records and amounts sampled evidenced that this was well managed. Records showed that staff are appropriately supervised and staff spoken with during the inspection confirmed this. Records showed that staff had received recent training in fire safety and manual handling updates. Staff spoken with confirmed this. Substances hazardous to health were seen to be stored securely. Records showed that equipment had been serviced regularly. Accidents were recorded and analysed and appropriate action was taken as necessary. Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 23 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 Requirement The registered person must make arrangements for the recording, safe handling, safekeeping, safe administration and disposal of medicines received including: • Handwritten instructions on the MAR charts must be signed, dated and counter signed. • A clear audit trail for all medicines must be kept and include the date of opening recorded on all short-lived medications, such as eye drops. Timescale for action 16/09/08 Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 24 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 Refer to Standard OP8 OP26 Good Practice Recommendations A suitable nutritional tool should be implemented to help with the nutritional assessments of all residents. Soap dispensers for hand washing should be affixed to the wall in the laundry area as good practice for infection control. The details of any verbal references taken for a potential staff member should be fully recorded in that staff members file. Different audits should be implemented to improve the quality assurance process. 3 OP29 4 OP33 Park Manor DS0000004055.V363382.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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