Inspection on 28/11/05 for Knowle Manor

This inspection was carried out on 28th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Knowle Manor 04/06/07

Knowle Manor 29/06/06

Knowle Manor 05/10/04

Knowle Manor 29/04/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Knowle Manor Tennyson Terrace Morley Leeds LS27 8QP Lead Inspector Mary Bentley Unannounced Inspection 28th November 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 Knowle Manor DS0000033246.V267152.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. Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Knowle Manor Address Tennyson Terrace Morley Leeds LS27 8QP 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) 0113 2534740 0113 2538728 Leeds City Council Department of Social Services Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15 June 2005 Brief Description of the Service: Knowle Manor is a local authority home providing personal care for 26 permanent and 3 respite places for service users over pension age. Accommodation is provided in single rooms, the majority of which have ensuite facilities. The home is on two floors and has a passenger lift. The generous communal areas are on the ground floor where there is a large dining room and a choice of lounges, one of which is a designated smoking area. The home is situated close to Morley town centre where there are a wide range of amenities including shops, library, doctors and dentists. The home is well served by public transport with bus services running to and from Leeds and other local areas. Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year, from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. This was the second unannounced inspection of this home; the first inspection was also unannounced and took place in June 2005. There have been no further visits to the home until this unannounced inspection. One inspector carried out the inspection between 10.00am and 3.30pm, before the visit time was spent planning the day. The purpose of this inspection was to assess the home against a predetermined selection of the National Minimum Standards for Older People and to check what progress had been made on meeting the requirements from the last inspection. The methods used in this inspection included discussions with service uses, relatives, staff and management, examination of records, and a partial tour of the home. Comment cards were left at the home for residents and relatives; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are shared with the provider without revealing the identity of those completing them. One comment card from a relative was returned and showed that they were satisfied with the care provided. What the service does well: What has improved since the last inspection? Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 Page 6 During the last visit service users and staff were a little anxious because the manager who had been in the home for seven years was leaving. At the time of this inspection the new manager had been in post for approximately five months, the change was well managed with minimal disruption to the day-today running of the home. Comments from service users and staff were positive and indicated they were happy with the new manager. At the last inspection there was concern about some service users in the home with a diagnosis of dementia. The concerns were that the home is not registered to provide care to people with dementia and that the needs of this group of people were not being appropriately met. The new manager has started to deal with this by arranging reviews for the service users concerned. The purpose of the reviews is to determine the precise nature of the service users care needs and to make a decision about where these needs can best be met. This is commendable and should continue. The organisation has improved recruitment procedures to make sure that all the required checks are completed before new staff start work. A lot of work has been done to make sure that service users are offered a regular and varied programme of suitable activities. 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. Knowle Manor DS0000033246.V267152.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 Knowle Manor DS0000033246.V267152.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): 3. Standard 6 does not apply to this service. Prospective service users are only offered a place in the home after their needs have been assessed and they have been assured that these needs will be met. EVIDENCE: Pre-admission visits are arranged for all prospective service users so that the home can carry out an assessment to make sure that they can meet the individuals’ needs. The duration of the visit varies and can be between one and three days. From discussions with the manager it was clear that she was aware of the limitations of the service in terms of meeting the needs of people with dementia and would only admit service users when they could be assured that their needs would be met. Knowle Manor DS0000033246.V267152.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): 7, 8 & 9 Overall service users health and personal care needs are met, however the absence of detailed, individualised care plans creates the opportunity for care needs to be overlooked. Service users are protected by safe systems for dealing with medicines. EVIDENCE: A lot of work has been done on improving the layout of the care records and making information easier to find. However the format, while it is a very good assessment document, does not lend itself easily to recording a detailed plan of care. A good care plan should give clear and detailed information on how and when care is to be delivered, during day and night, and with particular reference to the service users individual preferences and choices. The 24-hour summary of Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 Page 10 care needs, included in some of the files, provides some useful individualised information but it is a summary of needs and should not be seen as a substitute for a detailed plan of care. The records showed that one service user had a problem with weight loss. The manager was able to give an account of what was being done to deal with this but the records did not contain this information and there was no care plan that made specific reference to eating and drinking. The daily records for another service user showed concerns about behaviour but there were no instructions for staff on how to deal with this. The records showed that service users and their representatives are involved in discussions about care needs and there was ample evidence of involvement by other health and social care professionals. A relative said she was very happy with the care and felt she was kept fully informed by staff in the home, she was satisfied that whenever her relative needed medical attention this was arranged promptly. The home is in the process of introducing a new format for nutritional assessments. An inappropriate entry in one of the daily records was discussed with the manager, she was already aware of this and was dealing with it. The manager has identified that there are some service users in the home that may need a more specialised level of care than that provided at Knowle Manor, she is in the process of arranging reviews with the service users, their representatives and other professionals. A new medication system has been introduced and the supplying pharmacist has provided training for all staff involved in helping service users with their medicines. Controlled drugs were stored and recorded correctly. The manager said one service user was self-medicating and a risk assessment had been completed. The policies and procedures provide clear guidelines for staff to follow. Photographs were available for most services users and the manager said the rest had been requested. Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 Page 11 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. Information on the other standards is in the report dated June 15th 2005 Service users are given the opportunity to take part in a varied programme of social activities and are encouraged to take part in planning this programme. EVIDENCE: A lot of work has been done since the last inspection to make sure that a regular and varied programme of activities is offered to meets service users needs. A programme is displayed and feedback forms have been made available to encourage service users to give their views on what has been provided, recent trips to a local garden centre and pub have proved very popular. The home encourages the involvement of service users but efforts to organise a relatives meeting have not been very successful so far. A newsletter is now being produced for service users and relatives to keep them up to date with what is happening in the home. Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 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): 18 Service users are protected from abuse. EVIDENCE: While dealing with a recent incident in the home the manager showed that she has a good understanding of the procedures to be followed in the event of allegations or suspicions of abuse. Three senior staff are booked to attend Adult Protection training in January 2006. Staff spoken to showed a good understanding of the different types of abuse and how to report any concerns. Knowle Manor DS0000033246.V267152.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, 24 & 26 Service users live in a clean and comfortable home and have access to a safe outdoor area. EVIDENCE: The home was clean and there were no unpleasant odours, one visitor said the home is always clean. All parts of the home are decorated and furnished to a good standard, service users bedrooms are well equipped and it was clear that service users are encouraged to have their personal belongings around them. Since the last inspection the gardens have been attended to, new gates have been fitted and the manager said there are plans to paint the outside of the building next year. The home is well equipped with assisted bathing facilities and there are plenty of communal toilets that service users have easy access to. Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 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 numbers and skill mix of staff meets service users needs. Service users are protected by the recruitment procedures. Staff in the home appeared to be well trained and competent despite the fact that this was not fully evidenced by the training records. EVIDENCE: Duty rosters are available for all grades of staff. Care officers’ work between 7.00am and 8.00pm during the week and between 7.30am and 3.30pm at weekends. There are between 3 and 4 care assistants on the morning shifts and 3 on afternoon shifts. Overnight there are 2 care assistants on duty with a care officer on call in a nearby home. No concerns were raised about the availability of staff to meet service users needs. However the home’s administrative assistant’s post has been vacant for some time and this means that care officers are diverted away from care duties to carry out administrative tasks. The National Minimum Standards recommend that 50 of care staff are qualified to NVQ (National Vocational Qualification) level 2 or above by December 2005, at Knowle Manor 27 of care staff are qualified and a further three staff are working towards achieving NVQ level 2 or 3. Since the last inspection the organisation has made changes to the way in which new staff are recruited, this is now done centrally and all the required checks are completed before new staff start work in the homes. Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 Page 15 The organisation has a structured induction programme for all new staff that meets national guidelines. The training matrix was not up to date and it was difficult to get a clear picture of the current situation with regard to staff training. The manager confirmed that all staff had received fire training in July and September 2005 but a record of this training was not available for all staff. The records showed that 7 staff were overdue for Moving & Handling updates. Five staff are booked on dementia training and three senior staff are booked on adult protection training. Knowle Manor DS0000033246.V267152.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, 33, 35, 36 & 38 The home is well-managed and service users and staff benefit from an open and inclusive management approach. Service users financial interests are safeguarded. Overall the health, safety and welfare are promoted and protected. EVIDENCE: The new manager has many years relevant experience and she is doing an NVQ level 4. The law requires managers of care homes to be registered by the CSCI, at the time of the inspection her application was being processed. The home sends questionnaires once a year to residents, relatives, staff and other professionals involved with the home. The results of the recent survey have been analysed by the manager and an action plan has been put in place. Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 Page 17 The response rate was very good in some cases 100 and overall showed a high level of satisfaction with the service. The findings of the survey are shared with people who live and work in the home. A senior manager from the organisation carries out monthly visits to the home and reports of these visits are sent to the CSCI. The organisation holds the pension books for the majority of service users, these are held centrally. Service users are allocated a personal allowance and a weekly cheque is sent to the home for the relevant amount. Those people who can manage their personal allowance do so, for the remainder the money is held in safekeeping. Records are kept of all transactions and receipts are retained, the records are audited by the home every month and the organisation carries out financial audits randomly. The records showed that staff have regular supervision and appraisals, staff spoken to said they felt supported by the management team in the home. The records showed that weekly tests on the fire safety systems are done and that the home has regular fire drills. The records showed that most of the required maintenance and safety checks were up to date; the testing of portable appliances was overdue but was scheduled for later in the week of the inspection. Hot water temperatures are controlled by pre-set valves, however to further reduce the risk of scalding it is recommended that bath thermometers are used to check the temperature of bath water before immersion. Records of accidents were satisfactory. Notifications are sent to the CSCI when service users are found to have a serious injury or are admitted to hospital following an accident; it is recommended that the notification be made in all cases where service users go to A&E. Knowle Manor DS0000033246.V267152.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement The service users plans must set out in detail the actions that need to be taken to ensure all aspects of health, personal and social care needs are met. Previous timescales of 31/03/05 & 14/09/05 not met. Progress must be maintained to achieve the target of having 50 of care staff qualified to NVQ level 2 or equivalent. Accurate and up to date records of all training undertaken by staff must be maintained. Timescale for action 31/03/06 2 OP28 18 31/12/05 3 OP30 19 Sch. 2 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP27 Good Practice Recommendations The care officers’ surnames should be recorded on the duty rosters. DS0000033246.V267152.R01.S.doc Version 5.0 Page 20 Knowle Manor 2 3 OP27 OP38 The organisation should continue its efforts to recruit an administrative assistant to support care officers in their work. Bath thermometers should be used to check the temperature of bath water before immersion. The CSCI should be notified when service users attend A&E following an accident/incident. Knowle Manor DS0000033246.V267152.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Knowle Manor DS0000033246.V267152.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. 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!