Inspection on 01/11/07 for Madeley Manor Care Home

This inspection was carried out on 1st November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Madeley Manor Care Home 26/07/06

Madeley Manor Care Home 31/10/05

Madeley Manor Care Home 06/04/05

Madeley Manor Care Home 28/09/04

Madeley Manor Care Home 28/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Madeley Manor Care Home Heighley Castle Way Madeley Crewe Cheshire CW3 9HJ Lead Inspector Pam Grace Key Unannounced Inspection 1st November 2007 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 Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 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. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Madeley Manor Care Home Address Heighley Castle Way Madeley Crewe Cheshire CW3 9HJ 01782 750610 01782 751545 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) Madeley Manor Care Home Limited Patricia Webb – Acting Care Manager Care Home 42 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (42), Physical disability (5), Physical disability over 65 years of age (42) Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical disability minimum 55 years - 5 beds Date of last inspection 26th July 2006 Brief Description of the Service: Madeley Manor Care Home provides residential and nursing care for up to 42 elderly persons over the age of 65 years, physical disabilities elderly and older people, (42 beds) mental disability (5 beds), (excluding learning disability or dementia), dementia (5 beds) and physical disability minimum 55 years of age, (5 beds). The Home is a Grade II listed country house situated in landscaped gardens on the outskirts of Madeley in a well established residential area. The Home is approximately 5 minutes from Madeley village, 6 miles from Newcastle-under-Lyme and 8 miles from junction 15 of the M6 motorway. The Home is not well served by local transport but is easily accessible by car and has parking space to the front of the home. Accommodation within the Home is provided on three floors that are accessed by a vertical shaft passenger lift or a main staircase. All areas within the Home are accessible for wheelchairs. There are 32 single rooms and 4 double rooms, most of which have en-suite facilities. Madeley Manor has two well appointed sitting rooms overlooking the extensive grounds and a good sized dining room. There is access to the grounds and a newly laid patio area has been provided for the benefit of the service users. The Home provides a range of activities for service users and has access to a community minibus to provide day trips for those living in the Home. The General Manager confirmed that the fees for the service ranged from £330 to £805 per week depending upon individual resident’s needs and contributions. Additional charges were also made for newspapers/magazines, telephones, toiletries and hairdressing services. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was undertaken by one inspector, and conducted over a period of approximately 7 hours. The National Minimum Standards for Older People were used as the basis for the inspection. The methodology used for this inspection included pre inspection surveys i.e. “Have Your Say” documents sent out to residents, the completion of the Annual Quality Assurance Assessment document by the General Manager. Sampling of relevant records policies and documentation, a tour of the building, discussion with the general manager, acting care manager and administrator, discussion with residents and their visiting relatives. There had been two reported incidents involving residents, received by the Commission for Social Care Inspection (CSCI) since the previous inspection. Both incidents were dealt with appropriately and resolved by the acting care manager. Residents and relatives spoken with during the inspection visit were very positive about the care that they and or their relative received. Residents who could not communicate appeared well cared for and comfortable in their surroundings. There were 2 recommendations and no requirements made as a result of this unannounced inspection. What the service does well: The home offers residents a safe comfortable environment in which to live, where they can have a good quality of life and take part in daily activies and events. Residents can rest assured that their personal items will be looked after and cared for, with the peace of mind of an open visitors policy. Residents’ privacy and dignity is maintained at all times. All specialist equipment is regulary maintained and serviced in accordance with current legislation. Staff and residents can be assured that the equipment used is safe and fit for the purpose. The home is continually looking at ways to improve the service provided and with the help of feedback and residents’ questionnaires they will be able to Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 6 improve the service. 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. The summary of this inspection report can be made available in other formats on request. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 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 Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people who use this service and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: The inspector sampled residents’ care plans. Care plans seen evidenced that pre-admission assessments had been undertaken, and residents/relatives spoken with during the inspection visit said that they had received the home’s Statement of Purpose, and been able to undertake a trial visit before making a decision to move in. The general manager confirmed that following assessment, a letter is sent out confirming that the prospective resident’s needs can be met. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 9 The home does not provide intermediate care. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The inspector sampled 5 residents’ care plans, and spoke with staff, residents and visiting relatives. Care plans seen evidenced that the health and social care needs of residents were being met. However, care plans seen did not evidence that residents, and or their relatives/representatives had contributed towards the care plan review. Residents had access to a wide range of health professionals including: a GP, chiropodist, optician, social worker, physiotherapist etc. The medication records of those service users who were tracked as part of this inspection were examined and found to be accurate and complete. The general administration and storage of Medication was checked and found to be in good order, this included fridge storage temperatures, and the storage and administration of controlled medication. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 11 There were some very positive responses from residents and their visiting relatives, in relation to the care that they and or their relative received. For example, one resident said that a staff member had ensured that a health appointment had been kept, due to the staff member reminding the resident of the appointment. Another resident confirmed that the Doctor had visited on their request, and that they “had only to ask staff, and it was done”. One visiting relative said that they were aware that the staff get busy at times, but that this was generally accepted, and that generally the home was well run, and their relative receives good care. One resident praised the home, she said that she comes and goes when she wants, and she said “no problems love, it’s great here”. Staff were observed speaking with residents in an appropriate and respectful manner, and knocking on bedroom doors before entering. Residents’ Care plans seen contained a social history, there were risk assessments in place, where required, but one risk assessment was not up to date, and one care plan had not been reviewed. These were highlighted and discussed with the general manager during the inspection visit. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: Residents spoken with were happy with the variety of activities available within the home. Their comments included: “I like doing crafts and different things”, “Madeley Manor, is a nice place to live”, ‘‘I don’t have to join in unless I want to, sometimes I just want a bit of peace and quiet”. The acting care manager subsequently provided the inspector with the following information: Newspapers are provided upon request. There are weekly physiotherapy sessions provided. The hairdresser visits the home on a weekly basis. Residents’ outings are organised, which includes the use of a minibus. Religious services are held once a month. Chairobic exercise classes are held weekly. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 13 The inspector noted that there is an activities register. This is used to record the activities undertaken, and which residents attended the sessions. During the inspection visit, the relatives and friends of residents were seen being welcomed into the home at various times. Residents spoken with confirmed that they were able to make their own choices, get up when they wished and go to bed at times to suit them. During the inspection, lunch was served in the dining room where service users enjoyed their meal in a very pleasant environment, overlooking the rear garden. Menus were examined. They provided a balanced and nutritional diet for the benefit of residents, and are changed seasonally, with choices and input from residents. Positive comments were made to the inspector from residents about the food. They included the following: “The food is good here”, meals are “well cooked”, “I like the food; there is a good menu”. Residents confirmed that they are able to have their say at meetings in relation to the choices on the menu. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: There had been two reported incidents involving residents, received by the Commission for Social Care Inspection (CSCI) since the previous inspection. One incident was dealt with under the Protection of Vulnerable Adults and Safeguarding procedure. The other incident was dealt with by CSCI, and under the home’s complaints procedure. Both incidents were dealt with appropriately and resolved. The home has a clear complaints policy and procedure, and a grumbles book. The Complaints procedure is clearly posted up on the wall in the hallway of the home. Residents spoken with knew who to complain to, and said that the staff were very approachable. Residents said they were confident that their complaint would be listened to, and that something would be done about it. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 15 Staff spoken with were aware of the need to protect vulnerable adults, and of the POVA and Whistle-blowing Policies, however, there was a shortfall in that there was no evidence that training for this had taken place. It is a recommendation of this report that training in relation to POVA/Safeguarding is undertaken by all staff. The score of 2 for this standard reflects this shortfall. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 - Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well–maintained and comfortable environment, which encourages independence. EVIDENCE: The inspector undertook a tour of the building both inside and out. Overall, the home was well maintained. The general manager confirmed that there is a rolling maintenance and redecoration program for the home. The Annual Quality Assurance Assessment document (AQAA) completed by the general manager, confirmed that the home has an on site maintenance team, and maintenance programme. The general manager subsequently confirmed that there has been a high level of investment by the provider in relation to the re-decoration of the exterior of Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 17 the building, and a number of window frames have been replaced. The Dining room has been completely re-decorated to a high standard, and all dining tables now accommodate an adequate height for wheelchair users. The home provided a beautiful, homely and comfortable environment for the residents. Residents’ bedrooms reflected the personal care and attention to detail given to all residents, by the staff. Residents were encouraged to personalise their bedrooms, and to bring in personal possessions. The residents spoken with were happy living in the home. One resident said ‘It’s a marvellous place to live, what a lovely setting” another resident said “ aren’t we lucky to have such a view”. The standard of furnishings and furniture within the home were of a good quality and the home was immaculately clean throughout and a credit to the domestic staff. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. However, POVA/Safeguarding and other appropriate training should be kept up to date. EVIDENCE: The inspector spoke with 6 staff, and sampled staff records. The home has a recently appointed acting care manager now in post. She is a qualified nurse and is also a trainer in First Aid and C.P.R. She intends to take responsibility overall for staff training, and to this end she is looking at planning and arranging appropriate training for the staff at the home. The inspector noted that the acting care manager was in the process of establishing an up to date, comprehensive, and clear spreadsheet matrix for staff training, as well as individual and up to date training records for staff. Plans for future staff training were discussed with the inspector. The Annual Quality Assurance Assessment document, completed by the general manager, confirmed that the home currently has their own in-house moving and handling trainer. It also confirmed that 12 care staff have NVQ Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 19 Level 2 or above, and that 3 members of staff are in the process of undertaking the award. This meets the National Minimum Standard of 50 of care staff. The acting care manager subsequently confirmed the following staffing levels for the service, which show that there is a high ratio of qualified staff on duty during the day: 0800 1200 1600 2000 – 1200 2 Qualified and 7 Care staff – 1600 3 Qualified and 7 Care staff - 2000 1 Qualified and 4/5 Care staff – 0800 1 Qualified and 3 Care staff The recruitment and selection processes within the home were examined and found to be robust. Six staff files were examined, and each contained the following: a photograph of the relevant individual, an application form, an induction record, two references, a job description, a contract of employment, proof of identity and evidence of satisfactory criminal record bureau checks. Staff spoken with confirmed that they had undertaken mandatory training, including moving and handling and fire training. However, staff also confirmed that they had not received training in POVA, first aid, health and safety and infection control. It is a recommendation of this report that training needs are established for all staff, and that the training includes the above areas. The scoring of 2 for this standard reflects this shortfall. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,37 and 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The registered care manager moved on and left the home in February 2007. The general manager had worked at the home for a number of years and it was noted and acknowledged by the inspector that she had worked very hard to keep up the standards of the home, given that there had been changes in the care management structure. The recently appointed acting care manager is a registered nurse, and has yet to register with the Commission for Social Care Inspection. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 21 It was observed that a friendly and supportive ambience existed within the home with lots of friendly banter being exchanged between service users and staff. Staff were clear about their responsibilities and the general manager encouraged resident, relative and staff involvement and contributions in the development of the service provided. Updated and refresher staff training needs to be established for all members of staff, this is the area in which most work needs to be undertaken. The recommendations in this report reflect this. Monthly service user meetings continue to be held, records were available for the inspector to view. Overall, residents and their relatives/representatives were very satisfied with the services that they or their relative received. There were no complaints noted by the inspector at the time of the visit. The records viewed by the inspector in the home, and the Annual Quality Assurance Assessment (AQAA) document completed by the general manager, shows that safe working practices protect the health and safety of residents and staff. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 4 4 4 4 4 4 4 STAFFING Standard No Score 27 4 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X X X 3 4 Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP30 Good Practice Recommendations Care plans should evidence that residents, relatives and or representatives have contributed towards the review process. Staff should receive update training in Protection of Vulnerable Adults/Safeguarding, first aid, health and safety and infection control. Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection 1st Floor, Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 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 © 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 Madeley Manor Care Home DS0000059805.V349943.R01.S.doc Version 5.2 Page 25 - 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. 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