Inspection on 15/02/06 for Flixton Manor

This inspection was carried out on 15th February 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Flixton Manor 30/10/08

Flixton Manor 25/01/08

Flixton Manor 31/08/07

Flixton Manor 27/06/06

Flixton Manor 28/12/05

Flixton Manor 15/02/05

Flixton Manor 18/08/04

Flixton Manor 29/03/04

Flixton Manor 16/12/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Flixton Manor 2-8 Delamere Road Flixton Manchester M41 5QL Lead Inspector Nicholas E Allen Unannounced Inspection 14th March 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 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. Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Flixton Manor Address 2-8 Delamere Road Flixton Manchester M41 5QL 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) 0161 746 7175 0161 748 5583 Dr Jan Al Safar Julia Williamson Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. All service users will fall within the category of old age (60 ). Up to three service users who require personal care may be included within the maximum occupancy. Staffing levels as specified in the Section 25 (3) Notice dated 28th September 2001, shall be maintained. 8th December 2005 Date of last inspection Brief Description of the Service: Flixton Manor is a care home providing nursing care and accommodation for 32 older people. The home had been converted into one residence from two semi-detached houses. Further additions have taken place to enlarge the communal areas and an extension to provide bedroom accommodation. There was a large conservatory at the front elevation of the home that leads into the lounge and dining areas. Access to the home is from the drive and garden. This entrance was formerly the rear entrance of the original houses. At the end of the drive there is provision for parking. There are concrete steps and a ramp for wheelchair access to the entrance door. The home is situated on the main road between Flixton and Urmston. There was easy access to public transport, local shops and parks. It is convenient for the motorway system Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out in March 2006. The Registered Manager was on duty. During the inspection standards not inspected at the previous visit were inspected. The outcome of the inspection was that overall the home provided a safe clean environment for people to live in. There continued a programme of refurbishment. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 6 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 Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Service users and/or their families are offered the opportunity to visit the home and therefore make an informed decision about admission to the home. EVIDENCE: The manager or the assistant manager assessed all the service users prior to admission. The tool currently used for the pre-admission assessment was basic. It needed more detail to ensure that it was apparent how the decision had been made that the home could meet the needs of a particular service user. Care plans were in the process of being completely updated. A service user told the inspector that her family had looked around various homes and had chosen this one on her behalf. Contracts were not reviewed at this inspection; however, the service user was able to confirm that the first weeks of her admission were as a trial period while she settled in. Intermediate care was not provided. Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9,10 Service uses needs wee identified in care plans, but further developments were needed EVIDENCE: The care plans that had been produced were in sufficient detail, but the areas covered needed expanding to include all the activities of daily living that required some assistance. This should be completed once the new care plans have been introduced. Staff must also ensure that as a service user’s needs change the care plans are updated. The assistant manager was able to identify service users whose details had been moved onto a new care plan format. It was evidenced that this was a rolling programme and would be completed soon One file sampled was that of a service user who had been admitted to the home the week previously. Care plans had not yet been fully written, and base observations for risk assessments such as tissue viability and nutrition had not been fully recorded. It is expected that care plans should be written and base observations recorded as soon as possible after admission. Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 9 It was noted that where any problems were identified during routine assessments the appropriate support or equipment had been provided. For example a raised Waterlow score indicated the need for a pressure-relieving mattress. Service users spoken to choose the clothes they wished to wear, however some of the females did not have their legs covered either by stockings, tights or trousers and there was no indication that this was the service users’ choice. Staff were observed treating service users with care and dignity throughout the inspection. Of those Service Users assessed as able to self medicate non had chosen to Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 15 An activity co-ordinator provided a weekly programme of activities for service users that appealed to a variety of different tastes. The management team were introducing changes to practices that ensured the daily routines in the home were flexible to the needs and choices of the service users. EVIDENCE: There was evidence from a number of members of staff who said that there was a relaxed approach to them completing tasks, for example there was “no set time for people to get up”, or to “go to bed”. If someone wanted to return to their room after breakfast they could. Staff went on to say that this would be recorded in care plans and patterns of activities observed. The activity co-ordinator produced a weekly plan of events. This was based on both abilities and wishes of the individuals. The management team were insistent that service users could decide when they wished to get up and go to bed, and that there were no restrictions on them. She had spoken to all staff, both day and night, about providing a round the clock service and working to the needs of the service users and not their own. Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 11 Nutritional screening was part of the care planning process Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 A complaints policy was in place that would ensure complaints were dealt with appropriately. Advocacy services were available. The policy and procedures for protecting residents from abuse were appropriate. EVIDENCE: Complaints were investigated appropriately with the outcomes fully documented. The training matrix provided the manager with the opportunity to ensure staff were following the policies and procedures for the home. The home operated a whistle blowing procedure that protected Service users from abuse. All staff spoken to were aware of their role within this process. The homes recruitment processes were thorough and offered service users appropriate protection from abuse. The home had an advertised complaints procedure. A service user reported that if she were unhappy with the care she was receiving she would speak to the manager, even if it meant a member of staff might have to be told off. Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards were fully inspected at the last inspection. Areas identified had been addressed EVIDENCE: Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The skill mix of staff was sufficient to meet all assessed needs of residents. EVIDENCE: The manager made every effort to ensure that there was always a sufficient number of suitably trained and experienced staff on duty. The number of staff on duty reflected the needs of the service users and there was a higher number of staff on duty during the morning, when there was greatest need. Nurses, as well as care staff, were on duty at night. There was a strong emphasis on ensuring that all staff received appropriate training, most was organised internally. The manager was aware that staff had not updated some of the mandatory training and had made a matrix to identify the areas that needed to be covered and the staff that needed the training. The manager was planning to provide a training programme that encouraged staff to look at the holistic needs of the service users. The manager was aware of the need to assess service users in relation to the qualifications and experience of the staff team. Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The manager showed an enthusiastic approach to her role and had a clear vision for the home, which included all aspects of the provision of care EVIDENCE: Following the return to work of the registered manager a nurse with many years experience of working with older people in care homes and hospital settings. She had, together with the experienced assistant manager, identified a number of areas that required reviewing. These had commenced Staff spoke highly of the manager and her management approach and the enthusiasm she had for the home. One staff member reported, “She is what the home needs. She is fair but firm”. Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 16 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 17 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Flixton Manor DS0000006711.V278515.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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. 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