Inspection on 02/11/06 for 40a Manor Road

This inspection was carried out on 2nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

40a Manor Road 17/10/08

40a Manor Road 12/01/06

40a Manor Road 14/07/05

40a Manor Road 20/12/04

40a Manor Road 13/05/04

Similar services:

Ruskin Lodge

Clover House

Dystlegh Grange

The Good Companions

Cuerden Grange Rest Home

Springfield Cottage

Parkside

Park Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 40a Manor Road Upperby Carlisle Cumbria CA2 4LJ Lead Inspector Jacqueline Southern-Leigh Unannounced Inspection 02 November 2006 02:00 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 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 40a Manor Road DS0000022569.V296697.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 Adults 18-65. 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. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 40a Manor Road Address Upperby Carlisle Cumbria CA2 4LJ 01228 548118 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) The Glenmore Trust Mr Ian Andrew Waugh Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5), Physical disability (3), of places Physical disability over 65 years of age (3) 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 5 service users to include: up to 5 service users in the category of LD (Learning disability under 65 years of age) up to 5 service users in the category of LD(E) (Learning disability over 65 years of age) up to 3 service users in the category of PD (Physical disability under 65 years of age) up to 3 service users in the category of PD(E) (Physical disability over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 12th January 2006 2. Date of last inspection Brief Description of the Service: 40a Manor Road is registered to provide residential care for 5 people with learning disabilities, two of whom also have a physical disability. The home is operated by the Glenmore Trust, a charitable organisation providing services for people with learning disabilities throughout North Cumbria. The house is leased from Impact Housing Association who were responsible for repairs and maintenance. 40a Manor Road is a large detached bungalow, situated in the Harraby area, on the outskirts of Carlisle. There are local shops within easy walking distance and a regular bus service runs into the city centre. Service users share the purchase and running costs of an adapted vehicle, which accommodates wheelchairs. There are five people resident in the home, all have a single room with washbasin. There is a large lounge, dining room and kitchen with a separate utility. There is also an office/sleep-in room used by staff. Lifting hoists, high/low beds, plus a walk-in shower are provided to promote independence and provide a safe environment. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key Inspection, the Inspectors first visited the home on 30th October 2006 but were unable to undertake the inspection as there were no senior staff on duty. Therefore, the inspection was postponed until 2nd November 2006, commencing at 1.50pm and finishing at 5.30pm, there were two Inspectors present on this occasion. The inspection included a tour of the premises, meeting residents and speaking to staff on duty. Current fees for the home are £768 per week. What the service does well: What has improved since the last inspection? What they could do better: The furniture in the lounge area and bedrooms were all in good condition on this inspection, however there is a problem with damp in two of the bedrooms and the two bathrooms. This has been an ongoing problem and must be addressed as soon as possible before it becomes a serious health issue. The kitchen is also very old, basic and dated and needs to be replaced as soon as possible. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 6 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. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes assessment and admission process encompasses the needs and aspirations of the residents. EVIDENCE: The home has a stable core of residents, there has only been one change in the last year. When the place at the home became available the manager and his team felt it was essential to undertake a planned and thorough process to ensure that the home was able to meet the needs of the prospective new resident without any detrimental effect to the current residents. The transitional period when new people arrive in a small home is always difficult and needs to be managed carefully to ensure minimum disruption to all the residents in the home. The staff managed this process very well, all the residents are now settled in the home; the reduction of incidents of challenging behaviour is evidence of this. The home has a Statement of Purpose and a Service Users Guide available for the residents and their relatives; this explains the services and facilities available at the home. All contracts and agreements are dealt with and kept at the Glenmore Trust’s Head Office. The current fees for the home are £768 per week 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7,8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supports the service users in developing and evaluating their own lifestyle choices. EVIDENCE: The care plan/health plan looked at on the day of inspection contained very good detail about the needs, personal wishes and family involvement of the resident, there was also good detail about the likes and dislikes and the health needs and wishes of the resident. This plan could be strengthened and developed if the actions taken to meet the resident’s needs were recorded, so that outcomes are assessed and clearer. From discussions with the manager and deputy, it is evident that the home is taking this area seriously and is improving its system for recording the information collected. The Glenmore Trust has a residents group that residents from each home are able to join, at present no one from Manor Road wants to join this committee, but they may choose to do so in the future. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 10 The manager and deputy manager told us that the residents are involved in all the decision-making processes that involve their home. The manager said ‘the guys wouldn’t let us get away with any thing without them having an equal say’. They both agreed that it was vitally important that the residents were involved in all aspects of life at the home because it was their home. Staff told us that they encourage the residents to try new activities, and will support them in any new ventures, but they are very aware of the residents right to choose. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 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 provides a good system of support to allow the residents to make lifestyle choices. EVIDENCE: Residents at the home are offered the opportunity to take part in a good range of activities and also to pursue their own outside interests. Examples of these are; the Wednesday club at the Sands Centre offering bowling and ping-pong, these sessions are aimed at people with learning disabilities; Mencap runs a Disco once a month which most of the residents enjoy and like to attend. One resident wanted to join the trampoline club, this club is not specifically for people with disabilities, it was chosen because it offers the best option for the resident, a member of staff always goes with him, this is arranged by the staff having a flexible rota system to cover these circumstances. The home has its own mini van for the use of the residents; this is paid for in part by the resident’s mobility allowances. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 12 The relatives and friends of the residents are welcome at the home; they may choose to see them in the privacy of their rooms or in the communal areas. The home has policies and procedure regarding sexual relationships within the home for the protection of the residents; these policies also look at the resident’s rights as individuals. The staff in consultation with the residents plans the meals, they look to provide a balanced diet, the residents will also have take-aways or go out for a meal as you would in your own home. Meals are mostly cooked by the staff, some residents like to help which they are encouraged to do, and others choose not to help with the cooking. The shopping is usually done on a weekly basis, at present two staff go to the supermarket. The staff and organisation are currently looking at ways to allow them to do internet shopping as they feel this would save time which could be used in better ways for the residents. The home has policies on the rights of the residents. The Trust currently provides each resident with £700 a year that they can put towards a holiday or other activities, how the money is spent is the resident’s choice. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures the residents health, emotional and social care needs are met in a way that promotes their privacy and dignity. EVIDENCE: The staff are trained to provide personal care and support for the residents, all residents are offered the choice of having a bath or shower whenever they choose to have one. The manager and the staff team believe that ‘emotional care is part of the whole package’, the residents are encouraged to express their needs and the staff aim to support them. All medication is currently administered by the staff at the home via the Boots blister pack system. If a resident wished to administer their own medication a full risk assessment would be undertaken first to ensure the safety of the residents. The home is aware of the importance of supporting residents and their relatives during the last stages of life, some staff are to receive training on palliative care to further enhance their skills. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an accessible and transparent complaints system that protects the rights of the service users. EVIDENCE: There have been no complaints from residents, relatives or staff since the last inspection. The home has a complaints procedure and provides staff training on the protection of vulnerable adults. The manager and staff at the home told us that the views of the residents play an important part in the running of the home and decisions that are made regarding all aspects of care. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is in need of some essential maintenance to ensure it is able to provide the residents with a safe and hygienic home environment. EVIDENCE: The home is a one-storey bungalow; it has good local transport links into Carlisle and other local areas. The building is leased by The Glenmore Trust from Impact Housing Association. There are five bedrooms for the residents and a further bedroom that is used as an office/sleep-over room for the staff. Three of the five bedrooms are of a good size and are wheelchair accessible, the other two bedrooms are smaller, but they met the needs of the current residents. The bedrooms are all completely personalised to the resident’s choice and all have a washbasin. There is a good-sized lounge, with seating for all residents and a large TV, DVD player, the furniture in the lounge appeared to be in good condition and suitable for the needs of the residents. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 16 There is a laundry room with a sink, washing machine and tumble dryer, this is also the COSHH storage area, the cupboard was locked on the day of inspection and COSHH information was available for the items stocked. The laundry room is also kept locked. The kitchen has most equipment required for the safe storage and preparation of food, but the kitchen units, flooring and decoration are not in a very good condition. The staff informed us that the kitchen is on the list for replacement, I would suggest that the manager and The Glenmore Trust ask Impact Housing for a definite date for the replacement and up-grading of the kitchen. There are two bathrooms, one with a toilet and shower and one with a bath with a hoist and a toilet. Neither of the bathrooms are in particularly good condition, there is some corrosion and rust on the radiator covers and curtain rails. There are some tiles missing and grouting that needs cleaning or replacing. Hand towels were loose on top of the dispenser, which is not satisfactory in terms of infection control. The shower room has a small movable screen that is placed in front of residents when they are in the shower to protect staff from getting wet. I would strongly suggest that the Trust gets an Occupational Therapists assessment for both bathrooms to ensure they are appropriate for the needs of the current residents. Also of concern is the damp in the home, both the two smaller bedrooms have damp as well as the bathrooms, the manager and deputy informed us that they have repeatedly contacted the landlords about this situation but it has not been resolved. The home has tried different solutions themselves and has redecorated one of the bedrooms, but the underlying problem is still there. It is imperative that the Trust ensures the landlords deals with this problem immediately before it becomes an environmental health issue. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates good recruitment practices that ensure the resident’s needs are met by staff that are appropriately inducted, trained and have the correct skill base for the role. EVIDENCE: Staff files are kept at the Glenmore Trust head office, however the manager keeps basic information on file at the home. The Glenmore Trust has a good organisational policy on training and development. The manager and deputy told us that training needs are identified during 1:1 sessions and the training department are informed. Statutory training sessions are organised by the training department, these include first aid, manual handling, health and safety, food hygiene. The Trust has committed to train its managers to National Vocational Qualification level 4 or 5 in management and its care staff to National Vocational Qualification level 2. Staff spoken to felt that they received a good level of training. Supervision for staff is done on a regular basis; the records of these were seen by the second inspector on the computer system. Staff on duty reported that they ‘felt very well supported by both the manager and the organisation’, that 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 18 ‘there was good communication between staff’ and ‘it was a good organisation to work for’. Staffing levels appeared to be adequate for the needs of the current residents; the staff were quite flexible in their approach and adapted their shift patterns to support the needs of the residents. Each resident has one ‘home day’ when they receive 1:1 support from a carer and the resident is able to choose exactly what they do on that day, this ranges from visiting relatives, going shopping and train spotting. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 & 42 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 run and organised, it takes into account the needs and views of the residents. EVIDENCE: The Registered Manager is Ian Waugh, he is currently completing the National Vocational Qualification in Management. The Glenmore Trust carries out Regulation 26 visits to its homes, these visits are part of quality monitoring by the organisation. Staff also informed us on the day of inspection that the Trust is developing new quality assurance documentation. It was not possible to ask the residents their opinions on the home as the residents that were there during the inspection were unable to communicate with us verbally, however the interaction between the residents and staff on duty was positive and caring. In addition there have been no complaints made by residents or relatives over the last twelve months. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 20 The level of incidents of aggressive and challenging behaviour between residents has reduced dramatically over the last 18 months and in particular over the last year. This appears to be mostly due to the new approach the manager and his team are taking with the residents that has resulted in the residents being happier and more settled in the home environment, this has resulted in a de-escalation of incidents between residents. The home has policies and procedures on the safe keeping of resident’s money. Head Office deals with all fees for the home centrally. The home has Health and Safety policies in place; Fire training and equipment checks are up-to-date, as is the insurance and registration certificates. 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 X 3 X 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 22 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 YA24 Regulation 23 (2) Requirement The Glenmore Trust must obtain a date from Impact Housing Association for when the kitchen is going to be up-graded and replaced. The Manager must organise an Occupational Therapist assessment on the bathrooms for safety and suitability of residents. The Glenmore Trust must obtain a date from Impact Housing Association for when the damp problem in the bedrooms and bathrooms will be dealt with before it becomes an environmental health issue. Timescale for action 31/01/07 2. YA29 23 (2) 31/01/07 3. YA24 23 (2) 31/01/07 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 YA41 Good Practice Recommendations The Registered Manager must have a copy of all the training the staff in the home have undertaken. DS0000022569.V296697.R01.S.doc Version 5.2 Page 23 40a Manor Road Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 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 40a Manor Road DS0000022569.V296697.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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