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Inspection on 19/10/05 for Holmewood Manor Care Home

Also see our care home review for Holmewood Manor Care Home for more information

This inspection was carried out on 19th October 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users have the benefit of a fairly well maintained, homely and comfortable environment that is well managed. The care staff team are welcoming and friendly and are committed to promoting good standards of care and support for service users who live in the home.

What has improved since the last inspection?

This is the first inspection of this service as owned by Hallmark Healthcare (Holmewood) Limited, who were granted registration by the Commission in May 2005.

What the care home could do better:

The registered persons must ensure that the stated conditions of the home`s registration, which were formally agreed with them, are fully complied with.

CARE HOMES FOR OLDER PEOPLE Manor Residential Home, The Barnfield Close / Off Heath Road Holmewood Chesterfield Derbyshire S42 5RH Lead Inspector Sue Richards Unannounced Inspection 19 October 2005 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 Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manor Residential Home, The Address Barnfield Close / Off Heath Road Holmewood Chesterfield Derbyshire S42 5RH 01246 855678 01246 852953 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) Hallmark Healthcare (Holmewood) Ltd Mrs Vivian Gwendoline Ritchie Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Equipment must be provided for service users as detailed within the site visit letter/report dated 24.03.05. Timescale: 3 months. Upgrading, repairs and renewal must be completed to the building as detailed in the site visit letter/report dated 24.03.05 (three items). Timescale: Three months. This is the first inspection of this service for Date of last inspection Hallmark Healthcare (Holmewood) Limited, since their registration with the Commission in May Brief Description of the Service: The Manor Residential Home provides personal care and support for up to 40 older persons. It is located off the main road in the village of Holmewood, which lies to the north east of Chesterfield, close to Junction 29 of the M1 motorway. The home comprises of 34 single bedrooms, 10 of which have an en suite facility and three double bedrooms, all having an en suite. Single bedrooms without en suites have wash hand basins fitted. There is a choice of lounge and dining rooms to each floor, accessible by both stairs and a shaft lift. There are also a number of environmental adaptations and equipment provided to assist those with physical disabilities, although there is no loop system for those with hearing difficulties, who may benefit. There is level access to a well-kept garden with seating provided and also car parking spaces. Activities are organised on a regular basis, and details of these can be found in the entrance hallway. Twenty-four hour staffing is provided from a team of care support and hotel services staff. The registered manager is supported with the deputy manager and external management arrangements of Hallmark Healthcare Ltd. Catering and laundry services are centralised, although there is a small laundry facility for service users who may wish to launder personal items. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection was on the environment and the staffing and management systems and arrangements for the home. What the service does well: What has improved since the last inspection? What they could do better: The registered persons must ensure that the stated conditions of the home’s registration, which were formally agreed with them, are fully complied with. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 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. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Service users or their representatives were provided with the appropriate information to assist them with their choice to live in the home. Suitable written contracts/terms and conditions were provided for each service user (or their representative). EVIDENCE: The statement of purpose and service user guide was examined. These provided all information as is required in respect of the services offered by the home and key policy guidance. Discussions with service users and relatives indicated that these were made available to them. Hallmark Healthcare had sent out revised terms and conditions to all service users or their representatives for their agreement. The Inspector spoke with a relative about these and also about their involvement in terms of choosing a home with the service user. Feedback given by the relative indicated that proper support and information had been provided in throughout this process. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 9 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): The standards in this section were not assessed on this occasion. EVIDENCE: Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 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): The standards in this section were not assessed on this occasion. EVIDENCE: Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 11 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 There were satisfactory systems and arrangements in place to enable service users or their representatives to complain or voice any concerns they may have. There were appropriate safeguards in place, which sought to ensure the protection of service users in the home from harm or abuse. Staff were conversant with the proper procedures to follow in the event of any suspicion or allegation of abuse, although the home’s written procedure was not wholly accurate in respect of these. EVIDENCE: The complaints procedure for the home was displayed and also information as to how to complain was provided in the statement of purpose for the home and the service user guide. The Inspector examined the complaints records and discussed these with the manager. These were satisfactory. The Inspector also discussed with the manager and staff, the arrangements, which were in place to ensure the protection of service users in the home. This included staff training, care approaches and the operational policies and procedures provided in relation to this. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 12 Discussions with service users/representatives indicated that they knew who to approach in relation to raising concerns or making a complaint. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 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): 19, 20, 21, 22, 23, 24, 25 & 26 Whilst the home is generally well furnished, clean and comfortable, there are identified areas of upgrading and maintenance, which have not been complied with in previously agreed timescales and which are conditions of the registration of the home. EVIDENCE: A tour of the building was undertaken. The home was noted to be generally well maintained and furnished/equipped and also clean and comfortable. However, there are a number of areas requiring attention/remain outstanding, which were formally agreed with Hallmark Healthcare. These were to be achieved within a specified timescale and are specified conditions of registration under the care Standards Act 2000. The Environmental Health Officer had recently visited the home and made identified a number of requirements and recommendations in relation to the kitchen and catering arrangements. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 14 There had been no further visits from the Fire Officer since the registration of the home to Hallmark Healthcare Limited in May 2005. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 15 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 home was properly staffed and there were satisfactory arrangements in place for the recruitment, induction and training of staff employed. EVIDENCE: Details of staff employed, staff turnover and complement, together with that relating to their recruitment, induction and training were provided and discussed with both the manager and staff on duty. Associated records were also examined. A review of staff files was being undertaken by the registered manager to ensure that all proper information was in place in respect of each staff member employed. This was well underway with a target date set for its completion. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 16 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, 32, 34, 36, 37 & 38 The home is well managed by a competent person, who overall has recognised systems and strategies in place to promote the health and safety of service users, staff and visitors to the home. However, the manager has omitted to ensure that the proper and required servicing and maintenance of the home’s hot and cold water systems is undertaken. EVIDENCE: The Inspector discussed with the manager strategies for ensuring the proper management of the home, including the arrangements for communications and support with staff, service users and their representatives and also with the external management arrangements of Hallmark Healthcare Limited. Records were also examined in relation to these and were satisfactory. Discussions with staff were reflective of the systems and arrangements in place. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 17 The certificate of liability insurance cover for the home was openly displayed and was up to date. The Inspector also discussed with the manager and staff the arrangements to ensure safe working practises, including that relating to moving and handling, fire safety, first aid, food hygiene and infection control. A training matrix had been introduced to ensure that these areas of training were consistently offered on a rolling programme. A number of staff said that they had not all received basic instruction in relation to first aid. A number of key policies and procedures were also examined in relation to safe working practises and were satisfactory. Staff spoken with was conversant with these. Details of the arrangements for the ongoing servicing and maintenance of equipment in the home were provided. These were satisfactory, with the exception of that relating to hot and cold water system maintenance and Legionella testing. Compliance with this is specified as a condition of the registration of the home (see also Environment section of this report). The systems and arrangements for the reporting and recording of accidents and incidents were also examined and were satisfactory. Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 18 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 2 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X 3 X 3 3 2 Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? 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 OP18 Regulation 13(6) Requirement The home’s adult protection procedures must be amended to ensure that accurate information is provided in relation to the recognised lead role of social services in these procedures. Items of upgrading, repair and renewal, which are specified as conditions of the registration of the home, must be complied with. Timescale for action 30/11/05 2 OP19 13(4)c) 23(2)b)d) n&p 19/11/05 3 OP19 13(4(c)& 23(5) 13(4)(c) 4 OP38 Separate written confirmation must be provided from the responsible individual, detailing the action to be taken by him to ensure compliance with these, including the proposed timescales for their achievement. The requirements of the 31/12/05 Environment Health Officer (13/09/05) must be complied with as stated. The registered persons must 30/11/05 ensure that the annual maintenance and servicing of hot and cold water systems (including legionella testing) is undertaken. DS0000064198.V258421.R01.S.doc Version 5.0 Page 20 Manor Residential Home, The 5 OP38 13(4)(c) The registered persons must make suitable arrangements for the training of staff in first aid. 31/01/06 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 Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Manor Residential Home, The DS0000064198.V258421.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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