Care Home: The Old Manor House

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What has improved since the last inspection? Significant work and improvements to the building continue. The registered manager has addressed the requirements, and one of the recommendations, identified at the previous inspection. The people that live there continue to be happy with the care and accommodation offered. What the care home could do better: Care plans should provide more detail and direct staff as to the intervention needed to meet the individuals` care needs.. Hand written entries on Medicine Administration Records should show two signatures to evidence the accuracy of the entry. More could be done to demonstrate the lifestyle of the residents in the care records. Staff fire training must be regular and provided by a competent trainer. Key inspection report CARE HOMES FOR OLDER PEOPLE The Old Manor House 6 Regent Terrace Penzance Cornwall TR18 4DW Lead Inspector Alan Pitts Unannounced Inspection 7th April 2009 10:00 DS0000070049.V374829.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Manor House Address 6 Regent Terrace Penzance Cornwall TR18 4DW 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) 01736 363742 Mrs Mary Allison Anson Mr John Robert Anson Mr Kevin Barrie Edgar Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 14. 29th April 2008 Date of last inspection Brief Description of the Service: The Old Manor House is a care home registered to provide accommodation and personal care for up to 14 older people. It is in a quiet elegant terrace a short distance away from the sea front and to the centre of Penzance. It is a fine example of impressive listed Regency terraced town house. Some rooms have sea views. Most of the rooms provide single accommodation and currently there are no residents sharing a room. Access to the front of the building is via a set of railed steps. The building has four storeys. The upper three floors can be accessed via a serviced lift or stairs. Access to rooms in the basement, however is only via external steps that pass through the kitchen or by lift. The home has a small front garden with seating for residents, a lounge and separate dining room. Fees range from £355.00 to £415.00 per week. Additional charges are made for People who wish to have hairdressing, chiropody, dental services, opticians, and personal items such as confectionary and daily newspapers. The Old Manor House DS0000070049.V374829.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 took place over the course of approximately 5 hours on 7th April 2009. The registered manager was present throughout the inspection. We looked at documentation, such as care plans, toured the building, met with staff and residents, and took note of responses from residents about the care they received. The registered providers have made substantial financial investments in the home (e.g. rewiring), and improvements continue. Overall, there is no doubt that the home offers individualised care that meets the care needs of the people that live there. The registered manager’s approach creates an open, positive and inclusive atmosphere. The people that live there were very positive about the care they receive and the kind attention of the staff. What the service does well: The home allows people to retain their independence for as long as possible. Medicines are administered safely and some people self-administer. The people that live there are offered a choice at meals, and are able to choose to either have their meals served to them in their own rooms, or to dine in the home’s attractive main dining room, which is next to the kitchen. Visitors are welcome and there are plenty of people coming and going from the home so residents are not isolated. Lifestyle is determined by the residents as much as possible. Improvements to the building continue with more planned. The home has a new roof, boiler and heating system. Two rooms on the top floor now offer ensuite accommodation. 75 of care staff have achieved NVQ Level 2 or above, and the remainder are undertaking this training. Staff are supervised. The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Manor House DS0000070049.V374829.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered manager is proactive in ensuring the residents are well informed. Prospective residents may visit the home prior to making a decision about admission. The home does not offer intermediate care. EVIDENCE: The inspector examined care documentation and spoke with the registered manager. Many of the residents have lived at The Old Manor House for some years now. The home has a combined Statement of Purpose and Service User Guide, which is displayed in the entrance to the home. The registered manager said that this would also be provided to all the residents rooms. Discussion took place with the registered manager about developing the homes capacity The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 9 to provide alternative formats (e.g. video/audio). Each resident admitted to the care home is provided with a contract or terms and conditions of residency. The care notes of the person most recently admitted to the home showed that a full and proper assessment had been undertaken prior to admission. Prospective residents have an opportunity to visit the home, and the home works closely with families and other agencies to ensure that all parties are happy with the placement. The home does not offer intermediate care. The Old Manor House DS0000070049.V374829.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans are minimalist and do not provide sufficient information. Medicines are handled and administered safely. The registered manager and staff maintain a close relationship with the residents to ensure that their care needs are met, and their wishes known. EVIDENCE: The inspector spoke with the registered manager, residents, and staff, and inspected the care documentation. At the last inspection the registered manager said he was introducing a new system for recording care plans and related documentation. Two different formats for care plans were seen at this inspection. Each resident has in place a care plan. Care plans tend to use generic phrases, such as assist with washing. The care planning does not sufficiently guide and inform staff of the action that they must take to meet The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 11 peoples assessed and identified care needs. There was some evidence of care plan reviews with the involvement of the client or their representative, but this was not consistent. The care records provide evidence of health care professional involvement, for example chiropody and optician visits. Good arrangements are in place to meet individuals health needs and medical services are promptly accessed when required. Staff have been suitably trained in the administration of medication. The registered providers and staff maintain good relations with local GP surgeries. Comments received from the people that live there on the standard of care delivery at the home were very positive. All said that the registered manager and staff could do no more. There were no concerns expressed. The storage of medication is secure. The home uses a monitored dosage system. The Medicine Administration Records were inspected and seen to be in order. Each Medicine Administration Record has a front sheet with the persons’ photo on it for easy identification. Medicine Administration Records are normally pre-printed, but where it is necessary to hand transcribe an entry this should be checked as correct and show two staff initials. Three people selfadminister, with their medicines stored securely in their rooms. A medicine policy is in place. Staff undertake appropriate training in the safe handling of medicines. The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were seen to receive visitors and the visitors’ book shows they often do so, and that they are free to determine their own lifestyle. The residents were complimentary about the quality of the food provided. All were positive in their comments about life at The Old Manor House. EVIDENCE: Visitors are encouraged into the home and visitors were observed at the home during the course of the inspection. Visitors are free to visit without restriction. Residents are able to keep in contact with family and friends living in the community. Residents can choose to entertain visitors in their own rooms or perhaps in the lounge or dining room areas. Routines are very flexible and residents can make choices in major areas of their life. More could be done to show that activities are offered and available to all (even if the offer was declined). Records currently tend to say where the The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 13 resident spent their day rather than how. The home’s self-assessment form told us: • “One residents has requested Bingo every week; however, other residents have said they categorically do not wish to play bingo, or indeed increase the activities offered in any way. (many residents socialise in the community and with family and friends and experience a very active, and individual, social life). We give additional staff time to carry out individual activities (daily news discussions, crosswords, wordsearches, etc) for the few who do not have the same social network of family or friends”. • “Those residents who participate in activities do so at their own request, and can refuse if they so wish (they often do). They tell us that they prefer not to have too much provided in the home as several go out into the town, up the road for exercise, and visit with family and friends, either in the home or elsewhere. (Some are encouraged to arrange their own visits to their GP.) They say that they generally feel in control of their lives”. Residents are encouraged to be responsible for their own money for as long as they wish, and are able to maintain their independence, for example, collecting their own pension, paying for shopping and managing their own bank accounts. Observation of the interaction between the residents and the staff (including the registered manager) was very positive and contributes to the very pleasant environment at the home. Residents were seen to have personal possessions, and are free to determine their own lifestyle. The residents have confidence in the registered manager and staff. A varied menu is offered, and there is a record of food provided. Care staff also assist in the preparation of some meals. An Environmental Health Officer inspected the premises the previous day. The equipment in the kitchen is regularly serviced, maintained, and appropriate health and safety measures are in place. The dining tables were nicely presented. Residents were complimentary about the standard of cooking at the home. The cook was observed to go round asking people individually for their choice of meal at lunchtime. The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents confirmed that they are treated with respect and that their rights are protected. The registered manager and staff are proactive in ensuring the welfare of the residents. EVIDENCE: There is a complaints procedure, which explains that people can approach agencies, such as Department for Adult Social Care and Care Quality Commission, without first going to the registered manager or registered provider. The complaints procedure is included in the home’s combined Statement of Purpose and Service User Guide. The residents are a vocal group, who are well able to voice any concerns. Residents also said that they had confidence in the registered manager and staff to deal with any issues that were raised. There is a safeguarding (abuse) procedure and a whistle blowing policy, and all the staff have undertaken the local authority safeguarding training (Part 1). The registered manager said that he has undertaken the relevant managers’ The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 15 training. The registered manager is fully aware of the local multi-agency safeguarding guidelines. The home adheres to a robust employment procedure. The Old Manor House DS0000070049.V374829.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Old Manor House is a comfortable, well maintained property providing safe and pleasant accommodation and communal facilities for the residents. The registered providers are committed to improving the fabric and décor of the building. EVIDENCE: The Old Manor House offers a comfortable, pleasant environment, and the registered providers have already made significant financial investments in the property (e.g. rewiring) with more to be made. Improvements since the last inspection include: new roof; some new windows, redecoration and refurbishment of two top floor rooms to include en-suites; new washing The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 17 machine; and a new boiler and heating system. The registered manager said that a new carpet was on order for the lounge and dining rooms, and that a new hoist was also on order for the top floor bathroom. The registered providers have also made a planning application to install a hydraulic lift at the outside entrance to improve access to the home, and this would be of benefit to current and future residents. The registered manager also said that there were plans for the disused swimming pool near the property to be filled in and the area used for extra parking and a seating area. The home’s self assessment form told us: • “We are continuing to improve the home and consult with service users wherever they may be affected. The Old Manor is a listed building and some of the improvements have become somewhat prolonged in order to ensure compliance with listed building regulation. Over the last 12 months we have replaced the whole of the roof and rebuilt the dormer windows on the top floor to the front of the building. The chimneys (two) were found to be dangerous and both have been rebuilt; bulging walls which appeared to be subsiding under the weight of the chimneys have been rebuilt; six bedroom windows to the rear of the building have been replaced; all the sealed window units from the ground floor up have been replaced (all had ‘blown’ and were very cloudy); two bedrooms on the top floor have been renovated and improved with the addition of ensuite facilities; the communal bathroom on the top floor has been refurbished and the bath hoist repositioned to provide greater comfort for bathers; one of the two boilers has been replaced together with some new radiators; two bedrooms have had their existing en-suites refurbished; floor coverings in four other en-suites have been replaced; one bedroom on the first floor has had the actual flooring replaced (while the service user was in hospital) to both the bedroom and the en-suite, and redecorated; a new door and new flooring provided to the ground floor residents’ toilet; building work to the laundry has resulted in a leveling of the floor, securing of a manhole cover covering of open drains together with removal of a concrete ‘trip’ hazards as well as provision of a new washing machine; some new beds and new bedroom furniture provided; the kitchen has been painted and new worktops installed; new steps have been built to the front door in preparation for the platform lift (still subject to planning issues so lift cannot be fitted yet); the entire outside of the home has been painted and the hardwood window frames sealed and catches, restrictors and hinges renewed; floodlights have been added to highlight the front of the building and the car park has been relaid (it was collapsing into the neighbour’s drive); fencing between ourselves and the neighbour has been replaced; a hole in the external wall of the main house has been repaired; the opportunity to insulate the roof was taken whilst the roof was being replaced so this, together with the windows and new boiler, has resulted in a much more comfortable, warmer and draft-free home; both the lounge and the dining room have been redecorated. Improvements have also been made to the fire alarm system and the nurse call system”. The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 18 • “Following appropriate risk assessments, we consulted with residents (and families) at each critical stage of the building, as to whether they wished to remain in the home while the works were being undertaken, and without exception they all wished to remain. However, in order to carry out some of the internal works it was necessary to have one of the top floor bedrooms vacated, and we invited those residents to consider whether one or more of them might like a ‘holiday’ in Portreath where another of our homes is located. One lady was very excited at this proposal and she offered to move while the works were being carried out. The families of these residents were also involved. This allowed us not only to improve the structural fabric but also to make other improvements, such as installing two new en-suites to two of the top floor bedrooms”. There are sufficient toilets and baths in the home, which are spread out over four floors. Toilets are within easy reach of resident’s private and communal living space. Bedroom accommodation is spread out over all four floors. The home was warm throughout, well lit and well ventilated. All resident’s bedrooms are individually and naturally ventilated and upper floor windows are fitted with safety restrictors. Central heating is provided throughout the home and radiators are guarded. Lighting is domestic in character and sufficiently bright. The home has a passenger lift to enable access to all four floors. The home appeared clean and tidy and was entirely free from offensive odours throughout the inspection. There are written procedures on the control of infection and staff are provided with suitable equipment and training to prevent the risk of the spread of infection. All laundry is laundered on the premises. Suitable hand washing facilities and protective clothing are available for staff. The Old Manor House DS0000070049.V374829.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are well served by the numbers and skill mix of staff during the day, and staffing levels adjust according to care needs. Residents are in safe hands and are protected by the home’s recruitment practices. Staff are generally trained to do their jobs, though further improvement is possible. EVIDENCE: There are currently 12 staff, including the registered manager, of which 9 have achieved NVQ Level 2 or higher. The registered manager generally works Monday to Friday 9am-5pm in a managerial capacity, though occasionally will cover ‘on the floor’ for staff absences and holidays. At night there is one waking member of staff, though staffing levels are reviewed against care needs and the registered manager believes the current level is sufficient to meet residents’ needs. Night staff are supported by an on-call system. There is evidence of new staff undertaking a National Training Organisation compliant induction-training programme, but insufficient evidence of proper completion. Units are currently ticked off (√) with the programme signed off The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 20 on one date. There is no evidence offered of how each unit was covered or when (demonstrating that the training was provided over a period of time). Similarly, the home’s training record was not up to date and was incomplete (e.g. 1st aid training, fire training). It is not clear that staff training needs are properly assessed and monitored (including where staff may receive training at another care home in the group). One staff personnel file was inspected and seen to show the home’s adherence to a robust employment procedure. The file also showed a record of training undertaken. An example of a completed National Training Organisation compliant induction-training programme was also seen, though it was noted that this did not contain any notes or comments on the units completed. The Old Manor House DS0000070049.V374829.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The manager has been registered for approximately 22 months and has achieved the Registered Managers Award. The registered manager was observed to interact with residents and staff in a relaxed, professional manner. The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 22 The registered manager said that quality assurance surveys were sent out in January of this year, and the responses to these were being collated so were not available at the time of the inspection. We were shown blank copies of a new revised quality assurance questionnaires that are to be used in future. The home’s self-assessment form told us: • “We use audit tools which include: satisfaction surveys, one to one discussions with both service users and their families, resident meetings (not well attended; residents say they prefer one-to-one, or casual general conversations), and listening to staff who may have views on how service users feel. This has identified that residents and visitors are very positive about the service provided and the manner in which staff meet the care and support needs for those in our home”. The home has no involvement in handling residents’ monies, and holds no money for them. The registered providers ensure that there is sufficient cash flow to provide for residents day-to-day needs and there is evidence of investment to secure ongoing improvements to the home’s physical environment (see comments under the environment section of this report). A sample of staff supervision records were seen at the time of the inspection. There is appropriate insurance in place and regular and frequent maintenance and safety checks of equipment (documentation seen). The registered provider’s have made a significant investment in redecorating and refurbishing the home. The registered manager said that an external company is now employed for fire system maintenance and checks, and to provide all fire training. Fire training has previously been provided by the registered manager, who has not undertaken any specific training in order to do so. Fire training is not being properly monitored. The registered manager said that additional fire training would be arranged immediately after the inspection. The Old Manor House DS0000070049.V374829.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 The Old Manor House DS0000070049.V374829.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 OP7 Regulation 15 Requirement The registered manager must ensure that the care plans guide and inform staff of the action that they must take to meet peoples assessed and identified care needs The registered manager must arrange for all staff to receive fire training from a person competent to do so at regular and frequent intervals (in line with Fire Authority recommendations) Timescale for action 01/09/09 2. OP38 13 15/04/09 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 OP12 Good Practice Recommendations The registered manager should ensure that the care records show that activities are offered and available to all DS0000070049.V374829.R01.S.doc Version 5.2 Page 25 The Old Manor House 2. OP30 3. OP33 (even if the offer was declined), and reflect the residents’ lifestyle. The registered manager should ensure that the induction training records show evidence of how successful completion of units was achieved, and when. The registered manager should ensure that staff training needs are assessed and monitored. The registered manager should publish a summary of the findings of the home’s quality assurance questionnaires, including anonymous comments from those asked, and any action taken as a result of the findings. The Old Manor House DS0000070049.V374829.R01.S.doc Version 5.2 Page 26 Care Quality Commission South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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