Inspection on 14/11/06 for Manor Court

This inspection was carried out on 14th November 2006.

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 Court 14/12/05

Manor Court 28/07/05

Manor Court 29/11/04

Manor Court 04/05/04

Manor Court 04/11/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Manor Court 72 Church Street Market Deeping Lincs PE6 8AL Lead Inspector Mick Walklin Unannounced Inspection 14th November 2006 10:00 Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 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 DS0000002452.V319551.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 Adults 18-65. 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 DS0000002452.V319551.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Court Address 72 Church Street Market Deeping Lincs PE6 8AL 01778 344921 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) www.sense.org.uk Sense, The National Deafblind and Rubella Association Mr Mitchell Bixley Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2005 Brief Description of the Service: Manor Court is one of a number of care homes within the county operated by SENSE East. It is a single storey building with all bedrooms being for single occupancy. It is registered to provide care and accommodation for up to five service users who are deaf/blind. Situated in the town of Market Deeping it is conveniently placed for access to local facilities and shops. This home shares a site with Manor House, another care home and within the grounds are a patio, garden, hydrotherapy swimming pool, interactive multi-sensory room and administrative offices. Service users attend a day care facility in Bourne, also managed by SENSE. Transport is provided through the use of a minibus or via a regular bus service. The aim of the home as stated in its Statement Of Purpose document is to provide a safe and supportive environment based on best care values for people who are deaf blind. It confirms that the staffing of the home reflects service users individual needs. Manor Court is one of a number of care homes within the county operated by SENSE East. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was undertaken using a review of all the information available to the inspector regarding the service history of Manor Court, and through undertaking a visit to the home. The fieldwork visit took place over 7 hours. The main method of inspection used was called case tracking which involved selecting three service users and tracking the support they receive through the checking of their records, discussion with the care staff and observation of care practices. A tour of the building was undertaken with the manager. Documents connected with the running of the care home were also inspected. The manager had not received a pre-inspection questionnaire prior to the inspection, so this information was not received. He confirmed that the range of fees charged is between £1564 and £2147 per week. What the service does well: What has improved since the last inspection? The home already provides high standard of care. The work on the shower room has now been completed, so that the shower does not flood the hallway when being used. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are good procedures for assessing prospective service users, to ensure that their support needs can be met. EVIDENCE: One service user has been admitted to the home since the last inspection. She was admitted from a Sense home in Birmingham, which was closing. Because of the timescales involved in the closure, the manager said that the admission process had not been ideal, but staff had worked hard to ensure that the transition process had been satisfactory. The deputy manager had initially visited the service user at the home, and attended a transition planning meeting. The service user, her relatives and professionals involved had then visited Manor Court. There was a wide range of information provided for staff prior to admission, and a detailed review had been conducted one month after she moved in. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Care plans contain good information for staff to enable them to meet the support needs of service users. Staff communicate effectively with service users to ensure that their choices are respected. Risks to service users are minimised whilst they develop skills. EVIDENCE: Care plans contain excellent information about service users support needs. A pen picture gives good ‘quick reference’ information, with the care plan containing more detailed information about specific support needs, leisure activities, communication and preferred lifestyle. There are an excellent range of assessments for communication and behaviour management. Each service user has a Health Action Plan, which gives wide-ranging information about promoting health, and any special needs. All service users have a sensory impairment, and communication difficulties, and care plans contain hearing Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 10 and visual assessments. Care plans have annual review dates, but are in fact reviewed every 6 months with the person centred plan. All service users have some degree of communication difficulties, and use a variety of methods to communicate wishes and choices. Staff have an excellent knowledge of the individual methods used by service users, and outlined some of the techniques that they use, including signing, symbols and photographs. Service users have their own communication books, which staff can attach symbols or photographs. They are used to provide service users with a structured day, by sequencing activities. Staff were observed to be communication effectively with service users using a variety of methods, and offering choices throughout the visit. One member of staff said, “We have to learn signing as part of our induction, but some of the guys use their own signs, so knowing them is important”. Another member of staff said, ”We use photos a lot, so service users have good information to help them make a choice”. Service users participate in a wide range of outdoor activities, and there are excellent risk assessments in place to ensure that service users can enjoy these activities safely. There are also detailed risk assessments for behaviours that put service users at risk. Staff had a good knowledge of their responsibilities to allow residents to develop independence, whilst at the same time, ensuring that they are safe. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users have a busy and stimulating timetable. Contact with families and friends is encouraged. Catering arrangements are of a domestic nature, and are flexible to accommodate individual choice. EVIDENCE: Service users attend the Sense resource centre in Bourne during the week, and some have dedicated home days. Their timetables at the resource centre are varied, and there is a mixture of educational, vocational and recreational activities available. Activities at the home are less structured, in line with a normal home. One member of staff said, “There are some activities which require booking, which would be done in advance, but others we may decide on the day. We have a rough plan so activities are not duplicated”. Another Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 12 member of staff said, “We are out most evenings and weekends”. The manager explained that the home’s philosophy is to encourage an active outdoor lifestyle, and a range of equipment is available, including canoes, tandem trikes, and a trampoline. Service users were going climbing at a local leisure centre on the day of the inspection. The home has its own minibus, and access to other vehicles on site. There is good contact between service users and their families. Staff facilitate contact through visits, telephone calls and letters. Catering arrangements are of a domestic nature. Menus are prepared on a four-week rotation, and reflect resident’s choices. Care staff are responsible for shopping and the preparation of meals, with the help of service users. Service users are encouraged to assist in all aspects of shopping, meal preparation, laying tables, and clearing up. Staff demonstrated a good knowledge of individual service users like, dislikes, and dietary requirements. Menus encourage healthy eating, and are interesting and varied. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users receive a high level of personal support. There are good arrangements with local health providers, and medication procedures are robust. EVIDENCE: Each service user has designated social tutors. Staffing levels allow staff to provide high levels of personal support to residents. Service users preferred routines are clearly documented, and staff have a good knowledge of these. Service users are encouraged to be as independent as possible, and staff said that they may use ‘hand over hand’ techniques to assist them to carry out tasks themselves. Service users are registered with local GP services. There are satisfactory arrangements for dental care. Speech and Language Therapy, and Psychiatry input is available as required. There are good records of all medical consultations, and Sense staff conduct detailed vision and hearing assessments. Service users who require glasses use the local opticians, and Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 14 audiology is available through one of the Peterborough hospitals. Two service users access physiotherapy services through the day centre. Each service user has a detailed Health Action Plan, which identifies any health issues. A pharmacist inspected medication in April 2006, and commented “All storage and stock in good order”. There have been two medication errors since the last inspection, and action has been taken by the manager to prevent further errors. Medication is always administered by two staff to ensure safety, and storage facilities are satisfactory. Staff said that they receive administration training from Sense, and attend an annual refresher course. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Procedures for dealing with complaints and allegations of abuse protect service users. EVIDENCE: There have been no complaints since the last inspection, and staff were clear on how to deal with complaints, should they receive one. There is a good stepby-step guide in symbols for residents wishing to make a complaint. The home’s ‘Resolving Issues’ guidelines contain contact details for the Commission. Staff are required to complete an annual adult protection questionnaire as part of their appraisal. Staff interviewed had a good knowledge of the procedures for reporting suspected abuse, and were clear about the location of policies and procedures, including the Lincolnshire Adult Protection Committee procedures, a copy of which is displayed on the notice board in the office. SENSE East has a Protection Committee, which reviews all reports of adult abuse within the organisation. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides a clean, comfortable and well-decorated and maintained environment for residents to enjoy EVIDENCE: The home has a range of communal space, including a large kitchen/ diner, lounge and sunroom. The kitchen is due to be refurbished shortly. Service users bedrooms are personalised to their taste, and adapted to their needs. Some artwork done by service users is displayed in bedrooms and communal areas. Bedrooms have doorbells, which activate lights to alert service users when staff enter. There is an enclosed courtyard area to the side of the house, equipped with tables and chairs, and a bench. Service users also have access to a large grassed area to the rear of the property. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 17 Service users are encouraged to assist with room cleaning, and household tasks, and the home was clean and pleasant smelling at the time of the inspection. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are well trained and motivated. Recruitment and selection is robust to protect service users. EVIDENCE: Staff were enthusiastic about their roles, and demonstrated a commitment to helping service users develop. They said that there are enough staff to meet the needs of service users, and that they work “really well” together as a team. There are usually four staff on duty during the day, and two night staff. The manager works as supernumerary, and works alternate weekends. The deputy manager works two shifts per week, and is supernumerary for the remainder of the week. There are currently three staff vacancies. It was difficult to assess what training had been undertaken since the last inspection, as there are a several systems in place to record training undertaken, none of which appeared to be complete. The training department have their own records, and will notify the manager when training is due. However, staff said that they receive a good range of training, and those Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 19 interviewed said that they were up to date with mandatory training. One member of staff said, “We get 13 days training a year – it is really thorough”. A newly recruited member of staff said that her induction had been thorough and useful. She said, “I’ve really enjoyed it – my colleagues have been really helpful”. The home has a mentoring scheme for new staff, which she said had been very helpful. The files of three newly recruited staff were inspected. All contained evidence of a thorough recruitment and selection procedure, and contained the documentation necessary for the protection of service users. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home is well organised and managed. There are good quality assurance systems in place, and health and safety is well monitored. EVIDENCE: The manager is a qualified social worker, who is working towards the Registered Managers Award. Staff said that there is a good atmosphere in the home. There are regular staff meetings, and they said that their contributions are listened to and valued. Documentation is well organised, and regular health and safety checks are conducted. Sense employs a health and safety advisor who also conducts regular audits. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 21 Sense East has good systems for monitoring the quality of care provided on an annual basis. They use self-assessment questionnaires, staff focus groups and questionnaires for staff, purchasers and parents. There is an annual quality assurance cycle, with an external review being carried out every third year. A survey is currently being conducted. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 3 x LIFESTYLES Standard No Score 11 x 12 4 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 4 x 4 x x 3 x Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 23 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. 1. 2. Refer to Standard YA6 YA35 Good Practice Recommendations Care plans should contain 6 monthly review dates. Staff training records should be arranged in a way which clearly identifies training undertaken and training due. Manor Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 24 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 Court DS0000002452.V319551.R01.S.doc Version 5.2 Page 25 - 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. 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