Inspection on 10/11/05 for Manor Care Centre

This inspection was carried out on 10th November 2005.

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

Manor Care Centre 09/08/07

Manor Care Centre 04/10/06

Manor Care Centre 23/05/05

Manor Care Centre 18/11/04

Manor Care Centre 19/07/04

Manor Care Centre 23/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Manor Care Centre East Kirkby Manor East Kirkby Spilsby Lincs PE23 4BX Lead Inspector Roger Harrison Unannounced Inspection 10th November 2005 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 Manor Care Centre DS0000002664.V261694.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. Manor Care Centre DS0000002664.V261694.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manor Care Centre Address East Kirkby Manor East Kirkby Spilsby Lincs PE23 4BX 01790 763381 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) Halcyon Care Limited Care Home 41 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Old age, not falling within any of places other category (41) Manor Care Centre DS0000002664.V261694.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2005 Brief Description of the Service: The Manor Care Home is owned by Halcyon Care and is situated in the small village of East Kirby, which is approximately seven miles from the town of Spilsby. There is a post office, pub and church in the village. The home is a detached two-storey property and is a grade two-listed building with accommodation on ground and first floors. The first floor accommodation is serviced by a lift. It is set in its own grounds and gardens. The village is served by a regular bus service between the towns of Boston and Skegness. The home is registered for 41 service users, including up to 41 places for the category of Older Person and 3 places for individuals who have a Mental Disorder. Manor Care Centre DS0000002664.V261694.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken over a five and a half hour period, with the inspector using a method of inspection called “case tracking”. This involved selecting four residents who currently live at the home and tracking their experience of the care and support they have received during the time they have lived at the home. This was achieved by the inspector talking to the manager, touring the home, looking at information on care plans and files, talking to residents and care staff, and observing day-to-day care practice within the home. What the service does well: What has improved since the last inspection? The home is undergoing a further plan of refurbishment to ensure that the older part of the homes building matches the developments already in place at the home. Some carpets have been replaced and some re-decoration has been undertaken. The recording and storage of medicines is appropriate to ensure the safety of residents. The home has completely replaced its cal-bell system. The new system ensures that all residents have access to appropriate support as they need it. Manor Care Centre DS0000002664.V261694.R01.S.doc Version 5.0 Page 6 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. Manor Care Centre DS0000002664.V261694.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 Manor Care Centre DS0000002664.V261694.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. Service users are admitted into the home following a comprehensive assessment. EVIDENCE: The Manager confirmed that a pre-admission assessment is undertaken for any new resident in advance of any move. Information is provided to new residents, which includes a welcome pack and information leaflet about the home. Care plans examined were comprehensive and well kept. Each contained a detailed assessment, which had been undertaken prior to the individual’s admission to the home. Residents told the inspector that they had an opportunity to view the home before moving in and that they were supported in the process by the Manager. The home does not offer intermediate care facilities. Manor Care Centre DS0000002664.V261694.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): 9 and 10 Services users health, personal and social needs are set out in an individual care plan and are fully met. Residents are supported by the care team to ensure they able maintain their dignity, privacy and to live in the way they wish to. EVIDENCE: Individual care records included detailed care plans that evidenced the involvement of residents and relatives as appropriate. Individual risk assessments were in place, which are used as a basis for identifying and supporting residents in the way each wishes to live. Social care plans are used to reflect personal preferences and manager and staff were familiar with the individual care needs of all the residents of the home. Residents rooms and a quiet communal area of the home provide adequate private space for residents, who told the inspector that they felt their right to respect and privacy is always supported by the manager and care team. Residents are supported wherever possible to self medicate. However, at the time of inspection all residents required a level of support in maintaining safety with medicines. Records were observed to be maintained appropriately and storage for all medicines is secure. Care plans confirm there are good links to Manor Care Centre DS0000002664.V261694.R01.S.doc Version 5.0 Page 10 G.P.practices in the area and during the inspection a community nurse visiting the home told the inspector, “The new manager has made a difference here, we work well together to support residents and have a good relationship which ensures we sort things out as we go”. Manor Care Centre DS0000002664.V261694.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. Residents are helped to exercise choice and to maintain contact with family and friends. Residents feel that their cultural, religious and recreational needs are met. EVIDENCE: The home employs two activity Co-Ordinators who spend up to thirty hours a week undertaking activities such as, reminiscence, music and movement, and art therapy. A shopping trolley has also been developed which is popular with residents. The home provides support for individual religious and cultural needs, and each resident is supported to maintain this using a personal social needs plan. This sets out religious and personal preferences alongside details of how individuals wish to maintain their identity. Plans are actively used and reviewed by staff to ensure all wider needs are met. During the inspection the inspector observed residents, family carers and other professionals coming and going freely as they wished. The home’s “Visitors Book” recorded the frequent visitors to the home of family and friends. Residents confirmed that their visitors are made to feel welcome by the manager and staff of the home. One carer visiting the home told the inspector that, “This is a brilliant home, and I have heard other people also say how good it is here”. Manor Care Centre DS0000002664.V261694.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): 16 and 18. Service users and their relatives and friends are protected from abuse and can be confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: The home has a complaints policy, procedure and complaints record book in place, which the Acting Manager understands and uses to respond to any concerns raised. Since the last inspection there has been one formal complaint, which was responded to appropriately and resolved through action that the manager took to work with a resident and their family carer. The manager and staff were clear in their understanding of the complaints procedure and use the review process in place to encourage feedback from residents and carers. During the inspection the Manager confirmed that the home has a copy of the Adult Protection Policy and procedures, and that she understood her responsibility to safeguard residents. The Acting Manager told the inspector that staff had received awareness training regarding adult protection. This training was confirmed using training records and when the inspector met with three staff members who explained the correct process to would follow if they had any concerns. There have been no adult protection issues since the last inspection was undertaken. Manor Care Centre DS0000002664.V261694.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 and 26. The home is clean, comfortable and well-maintained, individual bedrooms were comfortably furnished and contained individual property and possessions. EVIDENCE: On the day of inspection the home was observed to be comfortable and well maintained. The acting manager told the inspector that a refurbishment programme had now commenced which has already led to the replacement of carpets where appropriate, decoration of main areas of the home, an aromatherapy machine in the reception area and sensory artwork on the walls in communal areas. The Manager showed the inspector artwork created by the residents to be used as part of the decoration of the communal dining area and confirmed that further refurbishment is being planned for the dining area and older part of the home, to include space for proper storage, which is currently limited. Individual rooms were observed to be clean, tidy, comfortably furnished and contained individual personal property and possessions. Manor Care Centre DS0000002664.V261694.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): 29. The manager maintains a robust procedure for recruiting, inducting and developing staff members, which promotes the safety and protection of residents. EVIDENCE: The manager confirmed that the home has a policy and procedure which ensures staff are recruited appropriately using references and all checks as needed in order to ensure that residents are supported and protected by staff in the right way. The Acting manager also confirmed that agency staff have not been used since last year, and three staff members confirmed through a meeting with the inspector that that they had received an appropriate induction and that the mix of skills available within the staff group helps in their individual learning and in working well as a team. The home has detailed training records and staff confirmed that they have benefited from increased opportunities to improve their skills, which encourages development through focussed NVQ training. A number of staff are already undertaking NVQ qualifications and are further supported in to develop practice through additional training sessions including administration of medication, adult protection training, and food hygiene. Manor Care Centre DS0000002664.V261694.R01.S.doc Version 5.0 Page 15 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, 35 and 38. The Acting manager has further developed her role, which continues to make a positive impact on the home, and the staff team in promoting the health, safety and welfare of residents. Residents are supported to safeguard their finances as they wish. EVIDENCE: The Acting Manager is a registered nurse and is to be interviewed by the Commission for the role of registered Manager. Since the last inspection the Acting Manager has commenced the Registered Managers Award. Members of staff described the manager as very open and supportive. Staff told the inspector that staffing levels are well maintained using rotas and accessing wider health professionals to ensure that health and welfare needs are met properly. Staff also told the inspector that, “The Manager is always available and very approachable” Manor Care Centre DS0000002664.V261694.R01.S.doc Version 5.0 Page 16 Residents described the manager and staff as very supportive, and during the inspection morale and rapport between members of staff and residents was observed to be very good. Residents are encouraged by the manager to maintain their own finances. However, where residents are in need of support the Manager has instigated a system for supporting and safeguarding their financial interests. This system is operated by a key administrative team member using detailed records, which were examined by the inspector. A random check confirmed that money stored on behalf of residents corresponded with the amounts recorded. The system also ensures that residents have access to their finances easily when needed. Manor Care Centre DS0000002664.V261694.R01.S.doc Version 5.0 Page 17 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 X 8 X 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Manor Care Centre DS0000002664.V261694.R01.S.doc Version 5.0 Page 18 NO. Are there any outstanding requirements from the last inspection? 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. Refer to Standard Good Practice Recommendations Manor Care Centre DS0000002664.V261694.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. 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