CARE HOMES FOR OLDER PEOPLE
Manor Court 8 - 8a High Street Moorsholm Saltburn-by-Sea TS12 3JH Lead Inspector
Ray Burton Unannounced Inspection 11th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 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 Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Manor Court Address 8 - 8a High Street Moorsholm Saltburn-by-Sea TS12 3JH 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) 01287 660747 Mrs Mary Elizabeth Wood Mr K Wood, Mr J Wood Mrs Mary Elizabeth (Molly) Wood Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One named individual under the age of 60 years be able to be admitted to the home. 19th May 2005 Date of last inspection Brief Description of the Service: Manor Court Residential Home is situated in the quiet village of Moorsholme on the North Yorkshire moors. Set back from the High Street, it is accessed via a private road. Its position in the centre of the village make for easy access to all community facilities: Church and Chapel; Memorial Hall; public house; shop. Accommodation is provided in fourteen single bedrooms (three with en-suite facilities) and three double bedrooms (one with en-suite facility). All bedrooms had been fitted with a washbasin and all met the spatial requirements of the National Minimum Standards. Communal facilities comprise dining room and two lounges, one of which is designated a smoking lounge. The home is registered to provide care for twenty persons. Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted on 11th January 2006 and was the second of two inspections required to be carried out each year to comply with the Care Standards Act 2000. What the service does well:
Converted from the local village school, Manor Court is a long established feature of the local community, and the building holds many childhood memories for several of the residents who attended as pupils. The home is managed and staffed by local people and the majority of the residents come from the surrounding rural area. Manor Court is very much part of village life and residents are able to take part in community events and activities and to maintain contact with relatives and friends. Life at the home is very relaxed and informal with routines that are flexible and take into account the personal needs and preferences of individual residents. Residents spoken to during the inspection said they were happy living at Manor Court and were satisfied with the care and attention given to them by staff. Twelve comment cards received from residents and their relatives each expressed satisfaction with all aspects of the home: “I am extremely satisfied with the standard of care provided which is very high. My mother is very happy. The staff are always pleasant and helpful.” “Any problems and the staff and I sort it out over a cup of tea.” “We are very happy with care given to our mother and consideration shown to all the family. There is always a warm welcome here.” One family member made the following comments in a letter written to the inspector: “Manor Court or “Molly’s” as it is affectionately known by us has over the past five years given us back our mum……………….. At Molly’s mum is independent and living her own life. She is well fed, much of the food being provided locally. She is always clean and tidy with regular visits from the hairdresser. Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 6 Her clothes are well laundered and it gives us pleasure to buy her new clothes knowing that she will wear them. She is happy and smiling when we visit and has a good relationship with all staff. We are always made to feel welcome and offered a cup of tea. We can honestly say that there is not one member of staff who does not earn our admiration and thanks for a job professionally done with pride and friendliness. Molly’s is open and honest. We feel it doesn’t matter when we go, with or without notice of a visit, we see everything as it always is and we appreciate this. Dementia is a very difficult illness. Molly and her staff have enabled both our mum and ourselves to still enjoy each others company. Mum is still very important to us. All of the residents are important at Manor Court, as is each and every member of staff. We would like to take this opportunity to pass on to you our feelings of gratitude, appreciation and thanks to Molly and the staff at Manor Court for a job well done.” 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. Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 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 Court DS0000000073.V251633.R01.S.doc Version 5.1 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 The home’s assessment procedure ensured no one would be admitted unless their needs could be met. EVIDENCE: Examination of residents personal files revealed that each contained comprehensive background information and detailed risk assessments. There was evidence that other relevant professionals and the resident’s family had been involved, and that prior to admission a needs assessment was received from a care manager of the placing authority. Following receipt of a referral an invitation was extended to the prospective resident and family to visit and meet with staff and residents and to look round the home. If the service user were unable to visit, the manager or a senior member of staff would visit the prospective resident in his/her own home or in hospital and conduct an assessment to determine if the person’s needs could be met at Manor Court. All admissions were subject to a trial period followed by a review before a decision was made about the suitability of the placement.
Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 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 Care plans contained information about the general health and social care needs of the individual and details of any specific ailment or medical condition. EVIDENCE: In conversation the manager and staff were able to demonstrate a good knowledge of each resident and his/her needs. Care plans contained information about the general health of the individual and details of any specific ailment or medical condition. Constant monitoring of health was undertaken and healthcare needs addressed by the resident’s own general practitioner and other community-based professionals e.g. community and specialist nurses, dentists, chiropodists, physiotherapists etc. Risk assessments had been conducted in areas such as mobility, risk of falls etc and appropriate risk management strategies developed so that health related needs could be appropriately and safely met and that, where necessary, specialist help and equipment would be obtained. Regular reviews ensured changing needs were recognised, and appropriate action taken. Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 10 One resident told the inspector: “Molly looks after us very well. The staff got me walking again.” A relative of one of the residents wrote to the inspector: “My mum needs constant care and a great deal of time is spent feeding her at every meal. They know everybody’s likes and dislikes and treat people with respect and understanding.” Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 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 were able to exercise choice and make decisions about their lives. Routines were flexible and able to accommodate individual preferences and expectations. EVIDENCE: The general atmosphere in Manor Court was relaxed and informal. Routines were flexible and able to accommodate individual wishes and needs. Residents confirmed they were able to exercise choice in all areas of daily living, they said they were able to rise and retire to bed at times that suited them and were able to have meals served in their own rooms if they wished. The manager and staff recognised the importance of residents maintaining links with their family and friends and confirmed that visitors were encouraged and always made welcome. Where possible residents were enabled and supported to continue with interests and hobbies they had pursued prior to becoming resident at Manor Court. One resident told the inspector that when he was farming he used to breed Cleveland Bay horses and that they remained on the family farm. He said he still entered them into local agricultural shows and pointed out the rosettes he had won that were pinned to the wall in the lounge.
Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 12 Residents were encouraged to take part in various activities and events both in-house and in the local community, however staff understood the importance of allowing residents the freedom to choose whether or not to participate and respected their decision should they decide not to. Regular activities include: musical afternoon; gentle exercise; games; quizzes; reminiscence therapy. In addition there were seasonal and outside events such as: Christmas shop; pie & pea supper; coffee afternoons; over 60’s club; Church Fete; lunch and shopping trips. Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 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): These standards were assessed during the inspection conducted on 19th May 2005. EVIDENCE: Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 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): These standards were assessed during the inspection conducted on 19th May 2005. EVIDENCE: Although these standards were not assessed on this occasion, a tour of the building revealed it to be maintained in a satisfactory manner and to be clean and hygienic and free from offensive odours. Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 15 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 The home had a suitable recruitment policy and procedures. Members of staff were employed in sufficient numbers to meet residents assessed needs. Members of staff were encouraged to undertake appropriate training. EVIDENCE: Observation during the inspection and examination of staffing rosters indicated adequate numbers of staff were on duty at all times to meet the assessed needs of residents. The home had a recruitment policy and procedures to ensure all necessary checks, including Criminal Records Bureau, were conducted and two suitable references received prior to commencement of employment. Staff spoken to during the inspection spoke enthusiastically about their work and displayed a good knowledge of individual residents and their needs. Training records revealed all staff received relevant training (including NVQ) that would aid their personal development and help them meet residents needs. Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 16 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): 31,32,33,35,36,37,38 The home was effectively managed and had policies, procedures and records to ensure the health, safety and welfare of residents. All members of staff received regular formal supervision. EVIDENCE: The manager has many years experience of working with older people both in a hospital and residential care setting, however to meet the National Minimum Standard she should hold appropriate qualifications in both care and management. Residents, family members and staff made positive comments about the management of the home and felt it was managed in an efficient manner. They felt the manager was approachable and listened to what people had to say and took notice of their comments and suggestions.
Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 17 It was apparent that the manager and all of the staff worked as a team and that this had allowed a friendly and relaxed atmosphere to develop where staff felt valued. The home had various systems in place to measure success in meeting its statement of purpose and objectives: regular reviews; formal staff supervision; reviews and updating of policies and procedures to reflect changing legislation and current good practice; residents satisfaction questionnaires; informal daily discussion with residents and relatives. Policies, procedures and records were in place and satisfactorily maintained to protect the health, safety and welfare of residents and staff. The manager and staff were aware of their responsibilities under health and safety legislation. Staff training was ongoing and covered areas such as: fire; COSHH; moving and handling; etc. The building, furnishings and fittings were regularly checked and serviced to maintain a safe environment. A designated representative, generally a family member, dealt with the financial affairs of residents and only small amounts of cash were handled by staff at the home. Any item of value held for safekeeping on behalf of a resident was held securely and an appropriate record kept. Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 18 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 3 3 Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 19 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 OP31 Good Practice Recommendations The Registered Manager should have a qualification at NVQ level 4 or equivalent in care and management by 2005 Manor Court DS0000000073.V251633.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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