Inspection on 09/08/07 for Manor Care Centre

This inspection was carried out on 9th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 04/10/06

Manor Care Centre 10/11/05

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 Ken Hague Unannounced Inspection 9th August 2007 08:00 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.V347980.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. Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Care Centre Address East Kirkby Manor East Kirkby Spilsby Lincs PE23 4BX 01790 763381 01790 763068 manorcarehome@aol.com 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 Mrs Kay Andrea Harrison Care Home 41 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number disorder, excluding learning disability or of places dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (3), Old age, not falling within any other category (41) Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service user in the category of DE(E) is for named individuals as stated in the Pre-Registration Letter, dated 11th January 2006 and 24 May 2006. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories:41 - (OP) Old Age, not falling within any other category to include up to:3 - (MD) Mental Disorder, excluding learning disability or dementia (aged 50 years and over), 3 - (MD/E) Mental Disorder, excluding learning disability or dementia over 65 and 1 named (DE/E) Dementia - over 65 The maximum number of service users to be accommodated is 41 3. Date of last inspection 4th October 2006 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. The home weekly fees ranged from £359 - £460 depending on the residents assessed needs. Additional charges are made for services such as chiropody, hairdressing and toiletries. Information about these costs as well as the dayto-day operation of the home, including a copy of the last inspection report, can be found in the home statement of purpose and service user guide. These documents are made available to all new potential residents and explain the resources and services offered, by the care home. A dedicated intermediate care service is not provided by the home. Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 8.5 hours. The registered manager and regional manager were provided with feedback at the end of the inspection. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them and the staff, and where more appropriate observation of interaction between staff and residents and related care practices. A sample of care records was inspected. Two members of staff were interviewed and the opinions of four residents were sought. It is normal procedure to obtain written feedback from residents prior to the site visit using a document called “have your say”. At this key inspection these document were not delivered due to a postal dispute. The opinions of the residents were sought however during discussions held at the site visit. Their views are reflected within this report. What the service does well: What has improved since the last inspection? What they could do better: The care home continues to operate at a good standard. No requirements or recommendations were made at this inspection. Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 6 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. Manor Care Centre DS0000002664.V347980.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 Manor Care Centre DS0000002664.V347980.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): Standards 3 & 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There are procedures in place which are used for the assessment of new residents to the service. This ensures that all of their personal care, health care and social needs are met. A dedicated intermediate care service is not provided by the home. EVIDENCE: Three resident’s files were examined as part of the case tracking process. They all contained a full assessment, including a risk assessment, for each individual resident. These had been completed prior to the resident entering the care home. If a potential risk was identified a risk management assessment plan had been put in place. Assessments sets out the care, social and health needs of each individual resident. The registered manager confirmed that residents are involved in the completion of care plans and in the review of their care plans. Signatures on the care plan support this statement . Staff also confirmed that residents are Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 9 involved in the review of their care plans. Residents were able to discuss the details of their care plans on the day of the site visit. A copy of a service users guide is placed in several public areas of the care home. A welcome pack an information pack was found in the reception area and in several public lounges. These documents informed residents other services and facilities offered by the care home. The registered manager stated that all residents are given an induividual copy of the homes service users guide. Residents spoken to confirmed that they did have a copy of this document. Manor Care Centre DS0000002664.V347980.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): Standards 7, 8, 9 & 10 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Care plans identify all areas of need and provide detailed care instructions for staff; this enables staff to provide appropriate care. Residents health needs are being met. Residents privicy and dignity is respected by staff. EVIDENCE: The individual care plans of three residents being case tracked had been completed using information from the initial assessment. These care plans had been reviewed formally at least twice a year. They contained risk assessments and risk management arrangements where appropriate. The choices and wishes of the residents were incorporated within care plans. This included the manner in which personal care should be provided, choice and wishes of social activities and goals for the future. Care Plans were discussed with staff and the individual residents who confirmed that the information recorded was an accurate reflection of their choice and wishes. The files of three residents being case track all contained the health care needs of each resident. There were details of health care assessments including nutrition and skincare. There were records of visits by community healthcare Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 11 visitors including general practitioners and district nurses. Evidence was found in files of chiropody and opticians services being provided. Residents confirmed in general discussions that they are provided with eye care dental care and foot care Staff have been trained in the administration and storage of medication. The registered manager checks the compenancy of each member of staff before they are allowed to give out medication. Medication records had been completed in accordance with the national guidelines. Drugs are being stored correctly. Staff and the registered manager stated that residents can self medicate if they wish to do so and a risk assessment confirmed that this would be safe practice. Residents stated that staff treat them with courtesy and respect. One resident said, I am completely satisfied with the staff of this home. they are careful and considerate and staff here are very good. A relative interviewed during the site visit commented I am very satisfied with the care practice, staffing and management of this home, my relative is very happy living here, I feel very sure after visiting the home that their needs are being met. Staff were observed to speak politely to residents during the site visit. Manor Care Centre DS0000002664.V347980.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): Standards 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities are provided for residents, which enables them to have an active and interesting social life. The home’s menu offers choice and meets the dietary needs of the residents. EVIDENCE: The registered manager gave the inspector a copy of a number of activities added to the programme since October 2006. Residents confirmed that the range of activities offered has been increased. The history and lifetime experiences of residents is recorded on their individual files. Staff stated that they discuss with the resident the type of activities that they would like to take part in. Some of these are on a one-to-one basis if appropriate. The home offers residents the opportunity to follow their own beliefs and lifestyle. Three different denominations hold religious services at the care home and Holy Communion is available. A relative spoken with discussed his satisfaction with the home and with the attitude staff. He said he was made welcome when he visited the care home. Care records provided evidence that the residents have choice and control of their social activities. They stated: we decide which activities we take part in. Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 13 Staff spoken with described the likes and dislikes of residents in terms of their diet and menu. The homes menu demonstrates choice and variations of diet. There were four residents spoken to during the site visit. They confirmed that their dietary needs are being met. They stated that food is of good quality and often there is too much for you to be able to eat it all. The food seen on the day of the site visit was seen to be of good quality and was served in a presentable and manner. Manor Care Centre DS0000002664.V347980.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): Standards 16 & 18 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from comprehensive complaints and adult protection procedures. EVIDENCE: Residents said that they knew how to make a complaint and were confident in been able to raise concerns with any member of the staff or management. The complaints procedure was displayed in public areas within the home and is found in the service users guide, a copy of which is given to all residents. No complaints have been received by the home or the Commission for Social Care Inspection since the last key inspection There is one incident, which is currently being investigated, which occurred in July 2007. The outcome is not yet known. The home took immediate action to prevent any reoccurrence of the incident. The registered manager stated that Staff have received trained in the recognition and protection of the residents from possible abuse. Staff confirmed that this training has been provided. Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 15 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): Standards 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a clean well maintained care home, which provides them with safe comfortable accommodation. EVIDENCE: The home has an ongoing maintenance program and a large amount of the work has been carried out since the last key inspection. This includes the redecorating of five bedrooms, the fitting of a new dinning room carpet and a new shower room. Repairs to one section of the roof have also been carried out and a new dishwasher has been purchased. Four residents expressed their satisfaction with the environment of the care home and their own individual bedrooms. Bedrooms are individualised by the residents. A resident said “I find my room very comfortable”. There were no health and safety issues identify during the site visit. Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 16 The exterior of the care home is well maintained, and car parks and garden areas are very presentable. Residents can sit out in the garden area in the summer months. The home is furnished to a high standard. Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 17 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): Standards 27,28,29 & 30 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents are supported by well-trained staff, who have been recruited safely using the up-to-date recruitment policy of the care home. EVIDENCE: Residents stated you do not need to wait for long if you need help. Staff answer call bells very quickly. Observations made during the site visit supported this statement. Staff stated that staffing levels are maintained at an appropriate level and additional staff is used if there is an increase in residents needs. They felt there is always sufficient staff on duty to meet the needs of residents. This included the nighttime period. Staff confirmed that they have been provided with training opportunities since the last key inspection include some specialised courses. The training plan and the training records of the care home supported these statements. There was evidence of all new care staff being given inductions. All care staff at the home are taking National Vocational Qualifications (N.V.Q). On the day of the site visit 60 of care staff held an N.V.Q. level 2 or equivalent, and 30 of care staff have an N.V.Q. level 3 or equivalent. Recruitment records for three new members of staff provided evidence that the homes recruitment policy is being consistently followed. All of the documents required by the care home regulations had been obtained prior to any member of staff commencing employment. Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 18 The residents stated that they felt safe living the care home. One resident said, “I can rely totally on staff to help me when I have any difficulty”. Staff stated the home was a safe environment to work in. There were no health and safety or infection control issues identified during the site visit. Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 19 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): Standards 31,33, 35, 38. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. There is positive leadership, guidance and direction to staff to ensure residents receive consistent quality care. Working practices promote the health and safety of residents. EVIDENCE: There is a registered manager in post who has obtained the registered managers award. Staff and residents stated that she is very approachable and supportive. Staff said that she is committed to ensuring services provided by the home are of a good quality. Residents stated that the home is run in their best interest. The registered manager demonstrated throughout the two days of the site visit a sound knowledge of the care home regulations and the commitment to ensuring quality care is provided by the home. Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 20 There are updated policies and procedures in place, which ensure the financial interest of all resident’s are safeguarded. The home only manages the personal allowance for some residents. Records are kept to demonstrate that the homes policy is being followed. Two staff signatures are necessary when money is given out to residents. There were no health and safety issues identified at this site visit. Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 21 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 22 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. Refer to Standard Good Practice Recommendations Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Manor Care Centre DS0000002664.V347980.R01.S.doc Version 5.2 Page 24 - 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!