CARE HOMES FOR OLDER PEOPLE
Manor Care Home East Kirkby Manor East Kirkby, Spilsby Lincolnshire PE23 4BX Lead Inspector
Ann Day Unannounced 23 May 2005 10:00am 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 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 Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Manor Care Home Address East Kirkby Manor, East Kirkby, Spilsby, Lincolnshire, PE23 4BX. Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01790 763381 Mr A Pradhan Halcyon Care Limited Care Home 41 Category(ies) of OP Old Age Both 41 registration, with number MD Mental Disorder Both 3 of places Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 18th November 2004 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 suffering from Mental Disorder. Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over one day in May 2005 and was undertaken by two inspectors. The Commission had received an anonymous complaint and an investigation of the concerns that were raised was undertaken as part of the inspection. Service users and members of staff were spoken to in addition to the current manager, Kay Harrison, who has applied to be registered with the Commission. The inspectors were given a tour of the premises and care records were examined. Attention was also paid to requirements left at the time of the last inspection. What the service does well: What has improved since the last inspection?
Nutritional assessments have been undertaken and recorded for individual residents. Fire extinguishers/equipment in the home is appropriately fixed and all fire precautions have been adhered to. The home is currently fully staffed and the home has not needed to use staff from agencies since late last year. Relationships between the staff and the present manager are good. Staff supervision is undertaken informally on a daily basis; formal supervision has been implemented recently. Documentation in the home has improved since the last inspection.
Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 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 Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 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 standard(s) 3,4 Service users are admitted into the home following a comprehensive assessment. EVIDENCE: Care records examined were comprehensive and well kept. Each contained a detailed assessment, which had been undertaken prior to the individual’s admission to the home. Care records have been reviewed and updated since the last inspection. The home does not offer intermediate care facilities. Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 Services users health, personal and social needs are set out in an individual care plan and are fully met. Medication records did not meet minimum standards. EVIDENCE: Individual care records included detailed care plans that evidenced the involvement of residents and relatives as appropriate. Individual risk assessments were in place and the use of accredited pressure area care was noted. The manager and staff were familiar with the individual care needs of all the residents of the home. One prescription of Controlled drugs received into the home had not been recorded or stored in accordance with regulations prior to disposal. This was remedied at the time of the inspection. Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 10 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 standard(s) 13,14,15 Residents are helped to exercise choice, maintain contact with family and friends; and receive a wholesome diet. EVIDENCE: The home’s “Visitors Book” recorded the frequent visitors to the home of family and friends. Service users confirmed that their visitors are made to feel welcome by the manager and staff of the home. Service users with varying likes and dislikes are encouraged by staff to exercise choice; staying in bed, resting on a couch, access to a lounge where the individual could smoke; going out and about shopping and visiting friends. One resident commented that they “would be scared to live alone now” Nutritional assessments are undertaken for all residents and these are recorded in their individual care records, as are individual likes and dislikes. Members of staff confirmed that residents are approached each day to choose from the menu for the next day. The home caters for special diets and new menus that offered a varied diet were available for examination. The manager explained how particular attention is paid to those residents who are diabetic; rigorous records are kept, and appropriate snacks and glucose rich supplements are identified for individual use.
Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 11 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 standard(s) 16 Service users and their relatives and friends can be confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: An anonymous complaint was received by the Commission, raising concerns about the care of residents at the home, particularly those residents who suffered with diabetes. The complainant also raised concerns about staffing and the management of the staff. An investigation into the concerns raised was undertaken as part of the inspection; all allegations were found to be unsubstantiated. The manager and staff were clear in their understanding of complaint procedures and welcomed the opportunity to demonstrate their openness. The home has a complaints policy and procedures which were available for inspection. Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19,22,24,25,26 The home is clean, comfortable and well -maintained, individual bedrooms were comfortably furnished and contained individual property and possessions EVIDENCE: The home was comfortable and well maintained. The manager told the inspectors that the home was awaiting refurbishment and redecoration in June 2005. The carpet on the upstairs landing was seen to have a number of wrinkles in it that might pose a slightly increased risk for those residents who are less mobile. Members of staff confirmed that the home had sufficient equipment for the safe moving and handling of residents. Individual rooms seen were clean tidy, comfortably furnished and contained individual personal property and possessions. The home was clean, tidy and free of any offensive odours.
Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30 Service users needs are met by, the appropriate numbers of trained members of staff. EVIDENCE: Currently the home is fully staffed, staff supplied by agencies have not been used since last year and staff confirmed that they work well as a team; and that they have sufficient time to spend with residents. One member of staff explained that when absences are planned, bank staff or existing members of staff are offered shifts. The home has detailed training records and staff confirmed that they have benefited from increased opportunities to attend training. Sessions included Administration of medication, adult protection training, and food hygiene. Three members of staff are undertaking NVQ Level 3 and four members of staff are currently undertaking NVQ Level 2. Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 The newly appointed manager has made a positive impact on the home and the staff team. EVIDENCE: The manager is a registered nurse and is to undertake the Registered Managers Award. She has applied to be registered with the Commission. Members of staff described the manager as very open and supportive: “ she makes staff aware of issues and will involve them in all aspects of the resolution of them; staff meetings, training, reviews” “ a good team, work well together and help each other out---feel valued as a staff member” “staff are not asked to work excessive hours” Residents described the manager and staff as approachable; rapport between members of staff and residents was good.
Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 15 Informal staff supervision takes place daily and formal supervision has been implemented since the last inspection Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 x x 3 x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 3 3 x x 3 x x Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 17 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. 1. Standard OP9 Regulation Reg 13 Requirement Ommission of appropriate recording and storage of medicines to be disposed of Timescale for action Actioned during the inspection 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 Good Practice Recommendations Manor Care Home C53 C04 S2664 Manor Care V229310 230505 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection 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
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