Inspection on 26/07/06 for Madeley Manor Care Home

This inspection was carried out on 26th July 2006.

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 01/11/07

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 Lynne Gammon Key Unannounced Inspection 26 July 2006 09:00 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.V305992.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.V305992.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 Julie McCormack 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.V305992.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 31st October 2005 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. On 26/07/06 information from the registered care manager identified that the fees for the service ranged from £315 to £620 per week depending upon individual need and contributions. Additional charges were also made for newspapers/magazines, telephones, toiletries and hairdressing services. Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was made on the 26th July 2005 at 9.00 am. The inspection was carried out by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 10 hours. Service users spoken to said that they were very happy living at Madeley Manor Nursing Home and relatives stated ‘Very satisfied with care given to my mother’ and ‘During the past 3 and a quarter years that my brother has been at Madeley Manor, I have been satisfied with the care and attention that he receives which in turn gives me peace of mind. Thank you’. What the service does well: The registered care manager and staff within the home, including the general manager, qualified nurses, care and ancillary staff, all contributed to a good standard of service provided within the home. Care plans and associated records were well documented and informative to enable staff to be clear about the needs of the service users and how those needs should be met. Recording within the care plans was thorough and meaningful. Health care needs were met very well and the medication was well managed promoting good health. Visitors were warmly welcomed and staff were friendly and open towards them. There was very good interaction between staff and service users, and service users were supported and encouraged to make their own choices and decisions about their own lives. Service users were treated respectfully and with dignity. Service users were very happy and complimentary about all the staff and the kindness shown to them. There were a range of social, religious and recreational opportunities available to meet the expectations of the service users within the home. A well balanced, nutritious and varied diet was provided for the benefit of the service users. Service users really enjoyed the food and one said ‘Meals are excellent, if you have to be in a home, I don’t think you would find one better’. Staff training had been provided and all care staff had received supervision. Staffing levels and mix were sufficient to meet the needs of those who lived in the home. Service users were cared for by qualified staff who were competent and trained to carry out their jobs. Recruitment and selection practices were robust for the protection of the service users. Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 6 The home was well managed and run in the best interests of the service users. Good robust quality systems were in place that enabled a structured, methodical process for obtaining feedback from both service users and staff. Staff should be commended for their commitment to providing a very good standard of care. 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. Madeley Manor Care Home DS0000059805.V305992.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.V305992.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Written confirmation was provided to service users that the home could meet their needs and visits were encouraged before moving into the home following in-depth pre-admission assessments. EVIDENCE: Service users and documentation evidenced that in depth pre-admission assessments took place to ensure both service user and provider was satisfied that needs could be met. A letter to confirm that their needs could be met was then provided to the service user prior to moving into the home. Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning processes were well documented and informative to enable staff to have a clear understanding of service user’s needs. Health care needs were met very well and the medication procedures were robust for the protection of the service users. Service users confirmed that they were treated with respect and their privacy honoured. EVIDENCE: Each service user had a documented care plan which provided comprehensive details of all aspects of daily living for each individual. These were reviewed monthly and were meaningful and well laid out. Risk assessments were in place and these were also reviewed monthly. Service users had access to a wide range of health professionals including: a GP, chiropodist, optician, social worker, physiotherapist etc. A number of Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 10 health care professionals returned completed questionnaires about the quality of the service provided at Madeley Manor and each one identified a high level of satisfaction. One commented as follows: ‘the home provides care to a high standard. Residents are well cared for. Staff liaise well and appropriately with ourselves. I would be happy for a relative to be a resident’. The medication records of those service users who were tracked as part of this inspection were examined and found to be accurate and complete. Observation and service users confirmed that they were treated respectfully and that their privacy was upheld. Staff and service users were observed having a friendly and courteous relationship with each other. Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 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, 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. A variety of activities were available for the benefit of the service users and they were encouraged and supported to maintain contact with family and friends. Service users were able to make their own decisions and choices about their lives and a nutritional and well balanced diet was provided in very pleasant surroundings. EVIDENCE: A range of activities was provided for the benefit of the service users and overall, they were complimentary about the variety of activities/hobbies available within the home. Some comments from the service users included: ‘I enjoy crafts and chairobics’, ‘I enjoy living at Madeley Manor’, ‘I enjoy chairobics’, ‘I enjoy crafts’, ‘I do not wish to participate at the moment, but I enjoy watching football’ and ‘I would like more trips to go on’. Throughout the inspection, relatives and friends of the service users were seen welcomed into the home at various times. Service users confirmed that they Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 12 were able to make their own choices, get up when they wished and go to bed at times to suit them. Menus were examined and seen to provide a balanced and nutritional diet for the benefit of the service users. Comments made to the Commission from service users about the food included the following: meals are ‘excellent’, ‘I enjoy the food; there is a good menu’, ‘food is very good – can’t beat it – good selection’. Minutes from a recent resident meeting also included confirmation that the residents were happy with the choices available on the menu. During the inspection lunch was about to be served in the dining room where service users enjoyed their meal in a very pleasant environment, overlooking the rear garden. Discussions with the service users confirmed that they were looking forward to their lunch and told of their high satisfaction with the meals in Madeley Manor. Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 13 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A robust complaints procedure was in place and service users were listened to with their views taken into account. The homes’ Adult Protection procedure ensured that service users were protected from abuse. EVIDENCE: The home and the Commission for Social Care Inspection had not received any complaints since the last inspection. Service users confirmed that they did not have any complaints and any minor grumbles were dealt with promptly and effectively. The complaints procedure was also available in the hall for visitors and relatives. No allegations of abuse had been received and procedures were in place for the protection of vulnerable adults. Also efforts were ongoing to access training to provide a refresher course in abuse awareness for staff to ensure the ongoing protection of the service users. Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 14 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The internal environment was safe and well maintained. Externally some areas of the building required attention but these were in progress of being addressed. The home was very clean and hygienic for the benefit of the service users. EVIDENCE: A tour of the home both inside and out, including the grounds, identified that overall the home was very well maintained to a very high standard. Externally, it was observed that a couple of windows required attention, particularly one in the dining room and a couple in the smaller lounge. These were noted as programmed for improvement in September 2006 in the ‘Madeley Manor Development Programme 2006’ provided following the inspection. The home has a reputation for maintaining its responsibilities and Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 15 gave an assurance that the windows will be renewed. This will be monitored by the Commission for Social Care Inspection. The home provided a beautiful, homely and comfortable environment for the service users. All who were spoken to were happy living in the home. One service user stated ‘I have lived at Madeley Manor for a long time now and love it here’. 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.V305992.R01.S.doc Version 5.2 Page 16 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and mix were sufficient to meet the needs of those who lived in the home. Service users were cared for by qualified staff who were competent and trained to carry out their jobs. Recruitment and selection practices were robust for the protection of the service users. Staff were well trained and proficient to meet the needs of the service users. EVIDENCE: Staffing rotas were examined and evidenced that adequate numbers of trained staff were on duty at all times to meet the needs of the service users. Discussion with the registered care manager confirmed that the home currently had 18 carers (including 3 qualified nurses from overseas) in the home with 5 care staff with NVQ Level 2 and 3 members of staff having achieved NVQ Level 3 in care. The recruitment and selection processes within the home were examined and found to be robust. Three staff files were examined and each contained the Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 17 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. Training records were also inspected and a comprehensive and detailed training matrix was seen. All mandatory training had been completed annually as required and a range of other training had been provided including infection control, in house dementia training etc. The registered care manager confirmed that she was one of two members of staff within the home who were accredited manual handling trainers. Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 18 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, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was managed and run by a competent person and of good character. Service users and relatives were encouraged to be involved in the development of the service. Staff supervision did take place and needed to be more formally recorded to ensure a documented record of each meeting took place as an audit tool for development. The health and safety of service users and staff was maintained to a high standard. EVIDENCE: Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 19 The registered care manager and the general manager had worked at the home for a number of years and it was observed that the home was well managed and efficiently run. The registered manager confirmed she had almost completed the training for NVQ Level 4 in care and the Registered Manager’s Award. It was observed that a friendly and supportive ambience existed within the home with lots of banter being exchanged between service users and staff. Staff were clear about their responsibilities and the manager encouraged service user, relative and staff involvement and contributions in the development of the service provided. Monthly service user meetings took place and records from those meetings evidenced that service users were very happy in the home and had ‘no complaints’. Questionnaires for service users and relatives were also seen and feedback from these was actioned accordingly. Formal staff supervision sessions were taking place and recorded, however a significant number were also informal and a considerable amount of effort was not being recorded. It is a recommendation of this report that these informal sessions become part of the formal supervision framework for the benefit of the manager and staff alike and to ensure supervision sessions take place six times per annum for all care staff. The records in the home showed that safe working practices protected the health and safety of service users and staff. Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 20 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 3 8 4 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X X 2 X 3 Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 21 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. Refer to Standard OP36 Good Practice Recommendations For informal sessions between the manager and staff become part of the formal supervision framework and to ensure supervision sessions take place six times per annum for all care staff. Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Madeley Manor Care Home DS0000059805.V305992.R01.S.doc Version 5.2 Page 23 - 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!