CARE HOMES FOR OLDER PEOPLE
Manor Court 31 Churchfield Lane Darton Barnsley South Yorkshire S75 5DH Lead Inspector
Mr Steven Vessey Unannounced Inspection 18th October 2005 09:45 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 DS0000018271.V260595.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Manor Court Address 31 Churchfield Lane Darton Barnsley South Yorkshire S75 5DH 01226 382321 01226 381299 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) Southern Cross Care Centres Limited Vacant Care Home 32 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (22) of places Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The DE(E) unit is on the first floor of the home. Date of last inspection 27th April 2005 Brief Description of the Service: Manor Court is a 38-bed care home for older people. It is in the village of Darton with easy access to shops, post office, church, local village club and health centre and is also on the main bus route. Residents are accommodated on two floors and the home has a passenger lift. The home has 28 single bedrooms, 7 of which are en suite and 2 double bedrooms. It has 5 lounges and 2 dining rooms. There are extensive gardens, which are mainly lawned with a safe enclosed area, garden furniture and a water feature. There is adequate parking at the front of the building. Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An additional visit took place on 22nd June 2005 to investigate a complaint made to the Commission for Social Care Inspection. This unannounced inspection took place over approximately five hours from 09:45 to 14:50. The inspection process included a partial inspection of the premises, inspection of a sample of records and policies, discussions with staff, residents and relatives and observation of staff carrying out their duties. The majority of residents and staff were seen during the inspection and the inspector had the opportunity to speak to eight staff, six residents and relatives in some detail. What the service does well: What has improved since the last inspection?
The residents and staff had benefited from the recent appointment of a manager. There were more opportunities for residents to participate in activities and residents stated they were happy with the level of activities and outings on offer. Some work had taken place to improve the environment for residents; this included the roof being repaired, some redecoration of corridors and bedrooms and the replacement of some items of furniture, fixtures and fittings in some bedrooms. Some stainless steel work surfaces had been provided to improve the food preparation area in the main kitchen. The information contained in residents care plans relating to nutrition had improved, residents needing assistance to maintain their diet and fluid intake
Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 6 were identified, the action staff need to take was clearly identified and there were clear recording of the diet and fluid intake of the residents. The manager and the administrator checked the money kept in the safe for residents monthly. 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 DS0000018271.V260595.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Standard 6 is not applicable at the home. All residents did not have a written contract of terms and conditions. Resident’s records included a detailed assessment of their needs. EVIDENCE: The manager and the administrator stated that some residents did not have a contract informing them of the terms and conditions of living at the home. The operations manager stated that company was in the process of producing new contracts, which would be distributed to the home soon and would then be implemented. Two care plans included an assessment carried out by staff from the home. Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Residents had a detailed up to date plan of care reflecting their identified assessed needs. Resident’s health care needs were met. Residents were treated with respect and their privacy was maintained. Residents were not fully protected, as some medication records were not clear and not fully completed. EVIDENCE: Two care plans included a risk assessment relating to nutrition. Some staff spoken to stated that they were involved in formulating and recording in residents care plans. Two care plans of residents assessed as having eating and drinking difficulties included detailed recordings of diet and fluid intake and residents were weighed more frequently if this was identified in their risk assessment, meeting the health care needs of residents. Residents seen were well cared for, they were clean, hair and nails had been attended to and male residents were shaved. Records were being kept of medication being received into and leaving the home.
Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 10 The health safety and welfare of residents was not fully met as there were some dates and signatures missing on the medication administration records for residents and some hand written instructions on the administration records were not clear. Records relating to the receipt and administration of controlled drugs were also unclear and not completed appropriately, two staff had not always signed the controlled drug register when medication had been administered, on one occasion a row had been left blank and the receipt of controlled drugs was not always clearly recorded in the controlled drug register. Care staff were able to describe how they promoted privacy and dignity when providing care for residents, nursing staff described how they monitored care delivery to ensure the privacy and dignity of residents was maintained. Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14 Residents were happy with the increased opportunities to take part in activities and outings. Residents were satisfied with the level of choice and control they had over their lives. EVIDENCE: Residents and staff stated that the activities on offer for residents had increased as a member of staff works three days a week to provide activities and outings for residents. The residents spoken to stated that they were satisfied with the amount of activities on offer. Staff stated that outside entertainers visited the home and a local church provided a religious service. Relatives stated that they observed staff regularly asking residents to participate in activities. Residents stated that they had been able to bring personal items into to furnish their bedrooms. Residents and relatives stated that they were happy with the arrangement for the management of their finances. Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents were protected from abuse by the policies and procedures in place and the training received by staff. EVIDENCE: A copy of the Barnsley Local Authority adult protection policies and procedures was available to staff. Staff spoken to stated that they were aware of policies and procedures relating to the recognising and reporting of abuse and had received training. Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 24 Areas of the home accessible to residents were in the main well maintained, however the main kitchen was still in need of upgrading. Sufficient bathing facilities were not provided. Resident’s rooms were personalised and in the main well decorated, however one first floor bedroom was awaiting redecoration. EVIDENCE: In the main the home was clean, well decorated and well maintained. The roof had recently been repaired following a leak and most areas of the home affected by water damage had been redecorated. Some stainless steel work surfaces had been provided in the kitchen to improve the food preparation area, however other kitchen refurbishment including the upgrade of the ventilation systems had not taken place. Sufficient bathing facilities were not provided; the previous requirement to replace the bathing facility on the first floor had not been met. Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 14 Residents and relatives stated that they were happy with the bedrooms and residents stated that they had all that they needed in their bedrooms. However one bedroom was still awaiting redecoration. Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 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 and 28 Sufficient staff with an appropriate mix of skills was on duty to meet the needs of residents. Some staff were NVQ level 2 trained, however more staff need to complete the training to reach the target of 50 of care staff trained. EVIDENCE: On the morning of the inspection there was the manager, the administrator, two care staff on the first floor, one senior care and one care staff on the ground floor and a member of staff providing activities for residents. There was also one domestic, one member of staff working in the laundry and the handyman working around the home. The rota showed that adequate staffing levels were being maintained. Staff and relatives spoken to stated that the staffing levels were adequate to meet the needs of the residents. The manager stated that NVQ training for care staff was continuing and approximately 45 of care staff had completed their NVQ level 2 in care. Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 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, 33, 35 and 38 The manager was experienced and competent to run the home, however she was not registered with the Commission for Social Care Inspection and had not completed her management qualification. Residents were asked their views about the home. A procedure on the handling of resident’s money should be available and the use of two signatures for financial transactions made on behalf of residents should be implemented to safeguard their interests. Residents and relatives felt that the home was safe, however all staff need moving and handling training to improve the level of safety for residents. EVIDENCE: The manager who had recently been appointed has nursing qualifications and has previously completed some units of the Registered Managers Award. The company had requested an application package to register the manager; this had not yet been completed.
Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 17 Staff stated that the manager and the operations manager consulted them about the running of the home and that staff meetings were held. Some staff stated that the operations manager speaks to residents when she visits. Records were available for residents whose money was in the safe. These included written records of every transaction with receipts for goods bought from outside the home. Staff were able to describe the procedure for handling residents money appropriately. Some residents spoken to stated that a small amount of money was kept for them in the office, they stated that they were happy with this arrangement and that they could get their money when they wanted it. Residents’ financial interests were not fully safeguarded as there was only one signature for the majority of transactions and a written procedure for the handling of resident’s finances was not available. However the manager stated that a monthly audit of residents’ finances had commenced. Staff spoken to stated that they had recently received fire training but had not received manual handling training. The hot water supply in one of the resident’s bedrooms was turned off; the handyman stated that this was because there was no thermostatic mixer valve fitted to that outlet and the water supply had been disconnected to reduce the risk of scalding. The handyman stated that the door to the fire escape at the top of the stairs automatically unlocked when the fire alarm was activated. Staff stated that when the fire alarm was activated one member of staff working on the first floor went downstairs for further instructions and the other member of staff remained on the first floor to supervise residents and ensure their health safety and welfare was maintained. Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X 2 X X 2 X X STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 2 Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard OP2 OP9 Regulation 5 13 Requirement All residents must have a written contract (Previous timescale of 30/06/05 not met). Records for the receipt and administration of medication must be clear and complete (Previous timescale of 31/05/05 not met). The kitchens ventilation systems must be upgraded (Previous timescale of 23/02/05 not met). The defective kitchen units and worktops must be replaced (Previous timescale of 23/02/05 not met). The first floor bathing facility must be replaced (Previous timescale of 30/12/04 not met). The identified electrical switch must be repaired or replaced (Previous timescale of 30/05/05 not met). The identified bedroom must be decorated. The manager of the home must be registered with the Commission for Social Care Inspection. Two signatures must be included
DS0000018271.V260595.R01.S.doc Timescale for action 18/01/06 18/11/05 3. 4. OP19 OP19 23 23 18/01/06 18/01/06 5. 6. OP21 OP24 23 23 18/01/06 18/01/06 6. 7. OP24 OP31 23 9 18/01/06 18/02/06 8. OP35 16 18/12/05
Page 20 Manor Court Version 5.0 9. OP35 16 10. 11. OP38 OP38 23 23 on resident’s personal money accounts, wherever possible one of these must be the resident (Previous timescale of 30/05/05 not met). A procedure for the handling of resident’s money must be in place (Previous timescale of 30/05/05 not met). All staff must receive moving and handling training (Previous timescale of 30/06/05 not met). All residents’ rooms must have a hot water supply maintained at a temperature of around 43 degrees centigrade (Previous timescale of 30/05/05 not met). 18/12/05 18/01/06 18/12/05 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 3 Refer to Standard OP28 OP31 OP38 Good Practice Recommendations Fifty percent of care staff to be trained to NVQ level 2 or equivalent by 2005. The manager should achieve NVQ level 4 in care and management by 2005. The fire procedure should include the level of supervision required by residents on the first floor when the fire alarm is activated. Manor Court DS0000018271.V260595.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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