Inspection on 15/01/09 for Hope Manor

This inspection was carried out on 15th January 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hope Manor 23/01/08

Hope Manor 22/07/06

Hope Manor 22/01/06

Hope Manor 19/11/05

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 16/02/2010.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Hope Manor 220 Eccles Old Road Salford Gtr Manchester M6 8AL     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Adele Berriman     Date: 1 5 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Hope Manor 220 Eccles Old Road Salford Gtr Manchester M6 8AL 01617887121 F/P01617887121 anngirgis@ntlworld.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Coveleaf Ltd care home 26 Number of places (if applicable): Under 65 Over 65 26 old age, not falling within any other category Additional conditions: 0 A maximum of 26 older people (OP) requiring personal care only may be accommodated. Date of last inspection Brief description of the care home Hope Manor is a 24 bed, privately run home for older people, providing personal care. The home is registered in the name of Coveleaf Ltd. The home is situated in a residential area of Salford on a busy main route and within close proximity to Hope Hospital. The home is accessible by public transport and major motor routes, such as the Manchester Ring Road. Parking facilities are available to the front of the house. The home is close to local shops, shopping areas, such as Salford City precinct, and other public amenities. The cost of the service is #395.00 per week. Care Homes for Older People Page 4 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We visited Hope Manor on Thursday 15th January 2009. Our visit was unannounced. During our visit we spoke to several people who live at Hope Manor, the manager of the service and two members of staff. We looked at a selection of records including care plan, staff files, medication records and policies and procedures. Before we made our visit the manager of the service had completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self assessment document that gives the service the opportunity to tell us what they do well, what they feel they could do better, what improvements they have made since our last key inspection and their plans for improvement in the next twelve months. Their completed AQAA told us some of the information we asked for. Care Homes for Older People Page 5 of 29 Five people who live at Hope Manor completed a survey form which gave them the opportunity to tell us their thoughts on living at the home. For this report we also considered all of the information that they have sent us since we last visited. What the care home does well: 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 7 of 29 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 8 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Before people move into the home more information more information needs to be recorded about their assessed needs to ensure they receive the care and support they require. Evidence: A representative of the service visits prospective residents prior to them moving into the home. The purpose of the visit is to carry out a needs assessment to ensure that Hope Manor has the facilities to meet the needs of the individual. We saw that a set proforma was available to record peoples needs relating to their medical and physical needs, medication, communication, religious needs, hobbies and the individuals perception of their situation. We looked at a selection of peoples personal files. We saw that little information had Care Homes for Older People Page 9 of 29 Evidence: been recorded about the persons initial assessment. Detailed information about peoples needs and wishes should be available at all times to ensure that their needs can be met at all times. Hope Manor does not provide intermediate care facilities. Care Homes for Older People Page 10 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A lack of written information about individuals care needs and wishes may result in people not receiving the care and support they require. Evidence: We saw that each resident had their own individual file that contained their care plan, assessments of need, risk assessments and personal information. We looked at three care plans during our visit. We saw that limited information was available about peoples identified needs and wishes. For example, peoples needs assessments had not been completed in full which resulted in little information available about what actions needed to taken to meet their needs. Detailed information should be available and reviewed on a regular basis to ensure that people receive the care and support they require. We saw no information recorded about peoples cultural or religious needs and how these needs were to be met. Information in the care plans failed to consider peoples Care Homes for Older People Page 11 of 29 Evidence: capacity to make decisions under the Mental Capacity Act (2005). Daily records were available for staff to record peoples activities throughout the day and night. We looked at a selection of these records, the majority of which contained little and contradictory information. For example, one persons daily records told us that they had been fine today. Been finding it hard to stand. Another record stated that the person had slept very well all night. No problems. The record then stated that the person had fallen out of bed at 3am. Failure to maintain detailed and accurate records may result in a persons health and wellbeing being put at risk. Staff demonstrated a good knowledge of peoples needs and wishes. However, the care planning and documentation did not reflect the service delivered. The majority of people who completed a survey form told us that they always receive the care and support they need. Most people who completed a survey form told us that they always receive the medical support they need and one person said that they sometimes did. Although the care planning documents gave the opportunity to record visits from health care professional, few of the documents were completed. They told us that the majority of medication was dispensed from the pharmacy in monitored dosage systems. Staff recorded on Medication Administration Records (MAR) when they had administered medication. We looked at several peoples medication records and we found that there was not always an accurate record of medication maintained. For example, one persons record stated that 100 tablets had been administered but only 80 had been dispensed by the pharmacist. Another persons records indicated that staff had administered medication on three occasions, however, the medication remained in its container. Other records did not contain sufficient information about what dosage of medication was to be given. For example, one persons medication administration record contained different information from that contained in the individuals book from the anticoagulant clinic. It is essential that detailed records are maintained of all medication administered. Failure to manage medication appropriately may result in a persons health being put a unnecessary risk from harm. A system for assessing risk should be developed to support people who are able to manage their own medication. During the visit we saw staff supporting residents in a respectful manner. Care Homes for Older People Page 12 of 29 Evidence: Care Homes for Older People Page 13 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a lack of provision of social and recreational activities which means that people do not have opportunities to participate in stimulating and meaningful activities. Evidence: People living at Hope Manor told us that they could receive visitors at any time. We saw no evidence of activities to meet individuals social, cultural or recreational needs. The manager of the service told us that she was in the process of reviewing what activities were to be made available and in addition, was planning to arrange some trips out for people. People should have the opportunity to access leisure, social and recreational activities in order to maintain their wellbeing. They told us that representatives from a local Roman Catholic church visit to offer communion to people. People told us in their survey forms that they sometimes liked the meals at the home and others told us that they usually liked them. One person told us that the food was Care Homes for Older People Page 14 of 29 Evidence: OK but there was no choice at mealtimes. Another person told us us we had lamb stew for dinner - it was lovely, you dont get a choice but there is an alternative if you dont like the main meal. They told us that following a recent review the menus available at the home were to be changed and include a choice of meals for people. Care Homes for Older People Page 15 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A lack of safeguarding procedures may result in concerns not being managed appropriately and people not being protected. Evidence: A copy of the homes complaints procedure was available in the service user guide that was located at the entrance to the home. They told us that they had received four complaints since we last visited, all of which had been resolved within 28 days. They told us that no written records had been maintained relating to the complaints they had received. Detailed records of all complaints, their investigations and outcome should be maintained at all times. People spoken to in the home were clear who they would go to should they have any concerns or worries. All five people who completed a survey form told us that they knew who to speak to if they had a complaint about the service. They told us that no safeguarding referrals had been made by the service since we last visited. The service did not have a copy of Salford Social Services safeguarding policy available. Staff should have access to safeguarding procedures at all times to ensure Care Homes for Older People Page 16 of 29 Evidence: that they are aware of what action to take if a safeguarding issue arises. Failure to follow appropriate procedures may result in peoples health and wellbeing being put at risk from unnecessary harm. We saw no evidence that staff had received awareness training in safeguarding adults procedures. During our visit the manager made arrangements for a representative from Salford Social Services Safeguarding Unit to visit the service to advise on policy and training. Care Homes for Older People Page 17 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Hope Manor provides a clean and comfortable environment for people to live. Evidence: We visited several areas of the home including bedrooms, bathrooms and communal areas. The bedrooms we visited were individualised with peoples person effects. Since we last visited new curtains and furniture had been installed in some areas of the building. We saw that not all bedroom doors were lockable. People should have the opportunity to lock their room to promote their privacy. They told us that one over ride key was available throughout the building for staff to use if they needed to enter a locked room in an emergency. All staff should have immediate access to an over ride key so that they are able to respond to an emergency situation immediately. Appropriate facilities were available for the management of peoples laundry. We saw that communal areas around the building were furnished with comfortable seating for people. Care Homes for Older People Page 18 of 29 Evidence: There was no fire risk assessment available for the building and several designated fire doors around the building did not fully close. We recommended that they contact the Fire Service for advice in these matters. The manager immediately made arrangements for a representative from the Fire Service to visit Hope Manor. A detailed up to date fire risk assessment should be available at all times to demonstrate how the service minimises the risk of fire. Care Homes for Older People Page 19 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment procedures need to be improved to ensure that people at not put at risk. Staff had not had routine training so the service they deliver may not be as safe as it should be. Evidence: We saw that two carers, the deputy manager, two domestic staff and the cook were on duty to meet the needs of people. The manager also arrived to carry out an afternoon shift. Three people told us in their survey forms that staff are always available when they needed them and one person told us that they usually were. They told us staff listen to them and act on what they say. During our visit people spoke positively about the staff team. These comments included everyone is very good who works here and staff are always around if you need them. The people who live at Hope Manor are supported by a team of staff that know them well. We looked at the staff files of four people who had been recruited since we last visited. The files contained the majority of information required, however, two files did not Care Homes for Older People Page 20 of 29 Evidence: contain evidence of identification. Three files contained evidence that appropriate Criminal Records Bureau checks had been carried out. One file demonstrated that the member of staff had been employed for approximately two months prior to an appropriate Criminal Record Bureau check being carried out. It is essential that appropriate checks are carried out prior to a person starting their employment to minimise the risk of people unsuitable for the role being employed. We saw little evidence recorded of training being made available to the staff team. The newly appointed manager of the service said that staff had recently undertaken training in moving and handling and arrangements had been made for several staff to attend medication training. They told us that they were in the process of applying for training opportunities for the staff team with Salford Training Partnership. It is essential that staff receive training to enable them to carry out their role in a safe and informed manner. Care Homes for Older People Page 21 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The current management systems do not fully ensure the efficient running of the home. Evidence: A new manager for the service had been in post since the beginning of January 09. She told us that she would be making her application to register as the manager of the service within the near future. They told us that there was no formal quality assurance system in place to measure how the service was being delivered. However, they told us that a residents and families meeting had recently taken place. They told us that it was a very positive meeting and planned it was have this type of meeting on a regular basis. We saw minutes to a staff meeting the had taken place several months ago. The information in the minutes suggested that night staff and day staff were to assist Care Homes for Older People Page 22 of 29 Evidence: particular people to get up in the mornings. This practice indicated that the service was not being managed in the best interests of the people who live at Hope Manor. It is essential that people have a choice in the time that they get up in a morning. They told us that they would immediately look into the matter. There were no records of people who had been admitted to, or left the home since we last visited. it is essential that accurate records are maintained at all times. We saw accident records that had not been completed in full and there was evidence that the commission had not been notified of some situations under regulation 37. It is essential that appropriate records are maintained at all times and relevant organisations information of any incidents that occur. The service provider must visit the home on a regular to ensure that the service is running appropraitely and peoples needs are being met. A system was in place for recording service users personal finance transactions. Not all of the finance recording documents we saw had been completed in full. Detailed records of all transactions must be maintained at all times to ensure a clear audit of peoples accounts can be made. We sawsome policies and procedures relating to the health, safety and wellbeing of people. they told us that the policies and procedures were in need of review and updating and this review would take place in the near future. Care Homes for Older People Page 23 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 Detailed information must be 04/04/2008 documented and available at all times in care plans that demonstrates what individuals? needs and wishes are, any identified risks and what actions are required to meet these needs and wishes. Care plans need to be reviewed on a regular basis to ensure that people delivering care and support have up to date information on how a person?s needs are to be met. Previous timescale of 14/03/08. Not reviewed at this visit. Medicines must be given to people as prescribed. Receiving medicines at the wrong time or not at all can seriously affect the health and well-being of people living in the home. 04/06/2008 2 9 12(1) 3 9 13(2) There must be a robust system of audit in place to ensure that staff are competent to handle medication and that people therefore receive their medicines correctly. 04/06/2008 Care Homes for Older People Page 24 of 29 4 9 13(2) Controlled Drugs must be kept in a legally compliant cabinet to ensure that these medicines are stored securely. To ensure the safety of all, the practice of wedging designated fire doors must cease and, if required, appropriate automatic door closures put in place. A detailed up to date fire risk assessment must be in place at the home at all times. Previous timescale of 14/03/08. Not reviewed at this visit. 04/07/2008 5 19 23(4) 04/04/2008 6 29 19 All staff files must contain 04/04/2008 the information listed in Schedule 2 of the Care Homes Regulations to demonstrate that appropriate recruitment checks have been completed. Previous timescale of 14/03/08. Not reviewed at this visit. Care Homes for Older People Page 25 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 12 Detailed accurate up to date information about peoples care needs must be available at all times. To ensure that people receive the care and support they need at all times 12/03/2009 2 9 13 Detailed records of peoples medication, its dosage must be recorded at all times. This is to ensure that people receive their medication when it was prescribed for. 12/03/2009 3 33 26 The provider, or their 20/03/2009 representative must visit the service on a regular basis and produce a report of their visit. A copy of this report must be sent to the Commission. This will ensure that a system of assessing the quality of the service delivered takes place Care Homes for Older People Page 26 of 29 4 33 37 The Commission must be 13/03/2009 notified of all incidents that occur within the home that are listed to Regulation 37 of the Care Home Regulations 2001 This will ensure that the service meets the requirements of Regulation 37 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 3 Detailed records of residents assessed needs should be maintained at all times, to ensure that staff supporting individuals are fully aware of what their needs are and that people receive the service they require. All risks relating to an individual administering their own medication should be considered and recorded to ensure the individual receives all of the support they require with their medication. Peoples social and recreational needs should be reviewed and opportunities to meet these needs made available. A varied menu should be made available at all times to ensure that people have a choice of what they wish to eat. Detailed records of all complaints, complaint investigations and their outcomes should be maintained. Detailed policies and procedures relating to safeguarding procedures should be accessible to staff at all times to ensure that any concerns can be managed appropriately. Staff should receive awareness training in arrangements for responding to safeguarding concerns. People should have, where possible, the opportunity to lock their bedroom door to promote privacy. All staff should have access to an over ride key to enable them to have instant access to a locked room in the event of an emergency. 2 9 3 4 5 6 12 15 16 18 7 8 19 19 Care Homes for Older People Page 27 of 29 9 10 31 38 All records must be completed in full. A full audit should be carried out of policies and procedures relating to the health, safety and wellbeing of all to ensure that they contain up to date information. Care Homes for Older People Page 28 of 29 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 29 of 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!