Inspection on 19/11/05 for Hope Manor

This inspection was carried out on 19th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Hope Manor 15/01/09

Hope Manor 23/01/08

Hope Manor 22/07/06

Hope Manor 22/01/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hope Manor 220 Eccles Old Road Salford Gtr Manchester M6 8AL Lead Inspector Sylvia Brown Unannounced Inspection 19th November 2005 08:15 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 Hope Manor DS0000063856.V264979.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. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hope Manor Address 220 Eccles Old Road Salford Gtr Manchester M6 8AL 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 788 7121 0161 788 7121 Coveleaf Ltd Mrs Christine Beasley Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 24 older people (OP) requiring personal care only may be accommodated. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Dependency levels of service users must be assessed on a continuous basis and staffing levels adjusted appropriately to ensure continued compliance with the minimum levels set out in the Residential Forum Guidelines, `Care Staffing in Care Homes for Older People`. First inspection under new ownership Date of last inspection Brief Description of the Service: 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. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Hope Manor was unannounced and conducted on a Saturday, commencing at 8:15am. The registered manager who was not on duty visited the home to meet with the inspector and receive feedback at the conclusion of the inspection. The deputy manager also facilitated the inspection, providing records and information as required. Time was spent with residents during mealtimes and as they sat in lounges. The inspector evaluated care practices and a sample of records relating to the care of residents, health and safety, recruitment and selection of staff, and complaints received at the home. The home was also evaluated regarding its progress to meet any requirements and recommendations arising from the previous inspection. This was the first inspection by the current inspector. This, along with the change of ownership and manager since the last inspection, prevented a full identification of how the home has developed since the last inspection. However, even though a number of requirements have been made at this inspection, overall the inspector concludes Hope Manor appears to be a pleasant place to live where residents are treated with dignity and respect. What the service does well: When spoken to, residents appeared to be happy and contented with the support they receive from care staff at Hope Manor. The home provides residents with pleasant accommodation and private facilities which are well maintained and adapted to meet their individual needs and preferences. Residents commented positively on the food served. The cook demonstrated, as did the deputy manager, a commitment to providing residents with a tasty and nutritious diet which they can receive when they prefer and where they desire. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 6 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. Hope Manor DS0000063856.V264979.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 Hope Manor DS0000063856.V264979.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 & 3 (Standard 6 is not applicable to the home) Residents have their needs assessed and receive information about the home prior to being accommodated. EVIDENCE: The home has a statement of purpose and service user guide which are provided upon initial enquiry. The registered manager stated she completed home assessments with the resident prior to them being accommodated. There was some indication that assessments were completed, however improvement in record keeping is necessary to demonstrate the process undertaken. Social Services’ assessments were in place for those who received funding support from the local authority. The registered manager confirmed there were nine residents with dementia and/or diagnosed mental health conditions. Observations throughout the inspection were that whilst they were supported appropriately, these residents were confused and required increased support and day-time occupation to Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 9 meet their specialised needs. The home’s certificate of registration states that the home may only accommodate up to 24 older people, not falling within any other category. A requirement is made to ensure the home remains within categories of registratrion and, where applicable, applies for a variation to its registration. Residents receive local authority contracts at the point of admission and on completion of the six week probationary contract, residents receive the home’s terms and conditions of residency. Residents must begin terms and conditions of residency at the point of admission, so they can clearly understand the implications of residency prior to completing the probationary period. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Residents have their care needs met and were treated with dignity and respect. Care plans were not appropriately maintained. EVIDENCE: Residents informed the inspector that they felt “very well cared for”. One resident stated that staff were “lovely and couldn’t ask for more”. They stated that they received support from medical professionals and that, in general, they felt well. The deputy and registered manager were knowledgeable regarding residents’ health conditions and how they were met. Evaluation of care files identified that they failed to detail the individual care needs and requirements of residents. Furthermore, there was no information to guide staff on how to meet identified needs or how residents prefer care to be provided. The inspector discussed with the registered manager ways in which record keeping could be improved to meet required standards. However, residents confirmed that they received good support and felt able to direct staff in how they preferred to receive support. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 11 Medication administration was observed. It was identified that the home’s practice was not safe. On one occasion, the medication trolley was left unattended, leaving medication free to be tampered with. Medication administration records had a significant number of omissions for prescribed medication, including Warfarin. Furthermore, medication with a choice of dosage, i.e., one or two, failed to identify what was administered. Records also failed to accurately detail the variable dosage for administered Warfarin. The home does not encourage self administration and, after discussion, it was evident that the self administration policy/procedure requires reviewing, as does the process to support residents where they are able administer their own medicines. The best practice of retaining a full list of staff with responsibility for medication administration and their signatures was not in place. Without exception, residents stated they felt well treated and respected. They confirmed that staff treated them with dignity and were respectful. Residents also commented on night care routines, saying they were not disturbed and that night checks varied, dependant on the residents’ needs and personal preferences. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 & 15 Residents maintain contact with families and friends and receive a varied and enjoyable diet. EVIDENCE: Throughout the inspection family and friends were observed visiting the residents. The home’s visitors record was completed appropriately, indicating all visitors entering and leaving the home. Some residents informed the inspector that they spend time with family members away from the home and visit places of interest with them. Other residents stated they enjoyed family and friends visiting and that the home makes everyone feel welcome. Every resident spoken to stated their satisfaction and delight at the food served. They informed the inspector of how food choices are made and of how they are able to chose from other options if the main meal is not desired. Observations were that residents were served a variety of options and that the cook had a good relationship with residents and was familiar with their everyday preferences. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 13 After spending time with the cook it was evident that he goes to some lengths to ensure residents receive a good diet. Fresh fruit and vegetables are included, as is a variety of fresh fish and meat. Advice was given to the registered manager to have occasional hot food options at breakfast for residents’ further enjoyment and to include such items as crumpets, tea cakes, etc., as options at supper to support the routine serving of toast. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home has complaint and adult protection procedures in place. EVIDENCE: The home continues to operate a complaints procedure, as identified at previous inspections. Though new staff are made aware of adult protection procedures at the commencement of their employment, through inspection of staff files and discussion with the registered and deputy manager, it could not be confirmed that all staff within the home had received up to date adult protection training. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 15 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 & 26 Residents live in a comfortable well maintained home. EVIDENCE: On the day of the inspection the home was found to be clean and free from odours. Residents confirmed that the hygiene standards were good and that Hope Manor was a pleasant place to live. The fitting of new carpets was being completed during the inspection; residents stated new carpeting was an improvement and “very nice and posh”. All communal rooms were observed to be bright and cheery. Currently, the home has a designated smoking area for residents and staff, however commencing on 1 January 2006, the home will become non-smoking. The registered manager stated that the one resident who smoked has given up and is receiving intervention and support to remain non smoking. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 16 The inspector observed a number of glass partitioned doors within the home; however, the registered manager was not sure if all glazing meets with required safety standards. For residents’ safety, glazing must meet required safety standards. Observation of residents’ bedrooms identified that they were maintained appropriately and furnished to meet the individual needs of residents. Residents spoke positively of their rooms, saying they had personalised them as they wished. They explained they have a call bell which could be activated if they required staff attention whilst they were in their rooms. Residents confirmed that if they summoned staff, they came promptly and met their request. The inspector observed a number of call points around the home without extension cords, which may restrict residents from summoning assistance. Five residents were identified as requiring hearing aids. The registered manager stated that the home was not equipped with a loop system which would assist their hearing when watching television or listening to music. Bathing and toileting facilities are equipped to meet the needs of all residents. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 17 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 Residents are not fully protected by the home’s recruitment and selection procedures. Improvements are required in the induction of staff and training to ensure residents’ safety. EVIDENCE: On the day of the inspection the staffing levels appeared to meet the needs and demands of the home. However, the staffing rota identified that, at times, staffing levels were lower. The registered manager confirmed that nine residents have dementia or mental health, 12 are incontinent, nine need two care staff to assist them and seven require assistance at mealtimes. Care staffing rotas must be reviewed on a daily basis to ensure that the needs of residents are met. Care staffing hours are further depleted at weekends, when there is no domestic on duty. Care staff confirmed that such dilution of care staff hours does, at times, prevent them from completing other duties, such as routine one to one support for the most dependant residents and providing general socialisation and activities for other residents. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 18 The duty rota for staff failed to identify staff’s employment position and night duty times were not recorded sufficiently to know commencement and completion times. The rota was not clear when staff are covering other duties, i.e., one care staff member’s rota did not separately detail that she covered kitchen duties, culminating in the rota appearing to have more care hours than it actually did. The registered manager was made aware of the requirement to ensure that the duty rota accurately reflects staff’s duties within the home in accordance with Schedule 4 of the Care Homes Regulations 2001. Staff files confirmed that the home operated a recruitment and selection process. However, of the five files evaluated, one had a CRB check relating to previous employment and two had no CRB checks evident at all. Three files failed to contain a current photograph of the worker and induction training was not sufficiently evidenced to comply with best practice set by Skills for Care which sets the benchmark for induction training for all levels of social care staff. The home operates a training programme for all staff. When asked, residents stated they felt in safe hands when receiving support. One resident saying “they are very good, they take their time and make sure I am ok”. Evaluation of staff files failed to confirm that some staff had received some essential training and/or updates in infection control, first aid, moving and handling and COSHH. The home continues to promote NVQ training and is working towards achieving recommended targets of 50 of staff receiving NVQ training. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 19 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, 33, 35, 36 & 38 Hope Manor is, in the main, a well run and managed home. EVIDENCE: Since the last inspection the new manager has successfully completed the process to become the registered manager of Hope Manor. The registration process identified that she had the relevant experience and qualifications for the position of manager. The registered manager visited the home to assist during the inspection. The inspector found that the manager was open and approachable. At feedback she expressed her opinion to learn and ensure that the home adapts its practices to meet the required standard. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 20 Care staff spoke positively of the registered manager and of the developments she has achieved since becoming the manager. The home has not completed quality assurance procedures since the new owners took over. The registered manager was unsure what the process would entail or when it would be completed. Such audits should include consultation with residents, relatives, visitors, staff and professionals involved with the home to seek their views on the services offered. A report of the outcome of the audit should be made available to the public and provided to the CSCI. As a consequence, a requirement has been made to ensure that a future quality assurance audit is undertaken which meets Regulation 24 and Standard 33. The home maintains records of all monies held on behalf of residents. Accounting systems were in place which identified auditing systems. Balance checks are co-signed by a second person to confirm balances and accounts are correct. Staff have supervision and the home operates a staff appraisal system to ensure their work practice and development over a year is evaluated. Health and safety records were evaluated. Greater Manchester Fire Authority inspected the premises in August 2004 which confirmed that the home was meeting Workplace Fire Precautions Legislation. The home continues to make routine checks on fire safety equipment and completes fire drill training with staff. Portable appliance tests were completed in February 2005 and lift testing was completed in November 2005. Environmental Health inspectors inspected the home in February 2005 at which time they awarded a silver for the good standard maintained. The home maintains a record of all accidents and occurrences. The manager stated that they are evaluated to identify common occurrences and patterns in order to reduce any risk or potential risk for residents, as far as possible. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 21 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 2 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 2 3 X x 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 x 3 3 x 3 Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 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 OP2 Regulation 14 Requirement The registered person must ensure that assessment procedures are completed with prospective residents to evaluate if the home can meet their needs. The registered person must ensure that residents receive terms and conditions of residency at the point of admission to the home. The registered person must ensure the home operates within its registration categories. The registered person must ensure care plans are in place which detail after assessment the residents’ care needs and how they are to be met. The registered person must ensure that medication is handled in a safe manner and never left on view and unattended during administration. Timescale for action 07/01/06 2 OP3 5 15/12/05 3 OP4 4 01/01/06 4 OP7 15 15/01/06 5 OP9 13 15/12/05 Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 23 6 OP9 13 7 OP18 13 8 OP19 13 9 OP22 13 10 OP27 17 11 OP27 18 12 OP29 17 The registered person must ensure that the home has an effective self-administration procedure which guides residents and staff in safe administration of medication and monitoring systems. The registered person must ensure that all levels of staff complete adult protection training. The registered person must provided the CSCI with confirmation that the glazing in doors meets required safety standards. The registered person must ensure all call points have extension cords attached to aid residents to summon assistance when required. The registered person must ensure that the staffing rota clearly details staffing positions, duties covered when changes are in place and the actual commencement and completion times. The registered person must ensure that staffing levels are reviewed on a daily basis and increased at peak periods and at times of higher demand to ensure residents needs are met at all times. The registered manager must ensure that CRB or POVA checks are received before new staff commence their first duty. The registered person must ensure that all staff files contain the required information, including current photo. 15/01/06 15/02/06 15/01/06 15/12/05 20/12/05 15/12/05 20/11/05 13 OP30 17 01/01/06 Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 24 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 OP22 Good Practice Recommendations The registered person should have a loop system fitted in parts of the home. Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Hope Manor DS0000063856.V264979.R01.S.doc Version 5.0 Page 26 - 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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