CARE HOMES FOR OLDER PEOPLE
Manor Court 31 Churchfield Lane Darton Barnsley S75 5DH Lead Inspector
Steve Vessey Unannounced 27 April 2005 09:30am
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Manor Court Address 31 Churchfield Lane Darton Barnsley S75 5DH 01226 382231 01226 381299 None Highfield Care Centres Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Georgina Ann Hewitt PC Care Home Only 32 Category(ies) of OP Old age (22) registration, with number DE(E) Dementia - over 65 (10) of places Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: The DE(E) unit is on the first floor of the home. Date of last inspection 4th November 2004 Brief Description of the Service: Manor Court is a 38 bed care home for older people. It is in the village of Darton within 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 had 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 J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours from 9:30 to 16:30. The inspection process included a partial tour of the premises, inspection of a sample of records and policies, discussions with the Operations Manager, 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 five staff, four residents and one relative in some detail. What the service does well: What has improved since the last inspection?
The home is continuing to provide NVQ training for staff, and the number of staff undertaking the training has increased. The manager has completed the NVQ level 4 qualification. Some redecoration had been carried out in communal areas and in resident’s rooms. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 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: Two out of three resident’s records had a contract informing them of the terms and conditions of living at the home. These were kept in individual files in the main office. The administrator stated that a contract was not available in the other file, as financial information had not been received yet from the local authority. The records did not all contain a full needs assessment provided by the local authority, but did include an extensive assessment carried out by staff from the home prior to admission. Assessments contained detailed information about all aspects of the lives of residents including assessments of risk and signatures of relatives or residents were evident in some assessments. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, and 9 Residents had a detailed up to date plan of care reflecting their identified assessed needs. Resident’s health care needs were met. Residents were not fully protected as medication records were not completed in line with the homes policy and procedure. EVIDENCE: Three care plans included detailed information as to the actions required from staff to meet the needs of the individual residents. Extensive risk assessments were included with, in the main, detailed information as to how staff should manage the risks. Some of the risk assessments contained information that relatives had been consulted. The three care plans had been reviewed regularly by staff and relatives had attended review meetings. A relative stated that she had not been to a review meeting, however the minutes of the meeting stated that she had attended. Residents seen were well cared for, they were clean, hair and nails had been attended to and male residents were shaved. Risk assessments were in place for, development of pressure areas, continence, falls and an assessment of the level of dependency was made on a regular basis. A nutritional assessment was in place, which was reviewed and updated regularly.
Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 10 Residents stated that if they were ill staff would contact the doctor who would visit however not all residents were aware of the name of their GP. Consent for staff to administer medication was recorded in the care plans, including reasons for residents being unable to self medicate, maintaining their safety. Records were kept of medication being received into and leaving the home. There was a medication administration record for residents, however there were some gaps in these records, including dates and gaps on the medication administration record, which should have been completed by the member of staff at the time of administration, not maintaining the health safety and welfare of residents. The home had a policy and procedure for the administration of medication, which stated that two staff should administer controlled drugs, however at times only one member of staff had signed the controlled drug register. On one occasion the controlled drug register had been completed and signed by one member of staff and the corresponding box on the medication administration record was blank, increasing the risk of errors in the administration of medication. One residents controlled drugs record was unclear showing two different totals for the number of tablets stored on the same page. Staff delegated to administer medication stated that they had received training and certificates were in staff files. All medication was stored appropriately and securely. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 12 and 15 Some activities and outings are provided but more activities and outings could be offered to encourage the participation of more of the residents. Residents receive a choice of food, which is of good quality and can eat in a pleasant dining room or their room, maximising their choice and comfort. EVIDENCE: Residents and staff stated that residents could choose when they get up and go to bed. Residents stated that if they did not like the food on the menu they could have an alternative and residents were offered a range of drinks during the morning and the afternoon. Residents were sat for long periods of time in lounge areas, watching television, in the first floor lounge residents were sat listening to music. Some staff stated more activities were needed; in the past these were provided by an activities co-ordinator, however this post is now vacant. One member of staff stated that if there were more staff we could do more with residents and a relative said there were not enough activities. Residents stated that they had not been out much recently, but they do go out in the summer. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 12 Dining rooms were pleasant and comfortable; tables were set prior to lunch and tea. Residents were positive about the food, comments included, “food is good, we get enough to eat” and “food is lovely”. The meal served in the first floor dining room was of good quality and well presented, staff sat and interacted with residents when assisting them to eat. Residents were served in a sensitive and unhurried manner. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 16 and 18 Residents were aware how to complain and thought that their complaints would be listened to and dealt with. Barnsley Local Authority Adult Protection policies and procedures were not available. EVIDENCE: A copy of the complaints procedure was displayed in the foyer. Residents spoken to stated that they had no complaints, but that they would tell staff if they were unhappy about anything and thought that any problems would be sorted out. Policies and procedures were in place regarding recognising and reporting of abuse, staff spoken to had attended abuse awareness training and a whistle blowing procedure was displayed in the foyer. Staff stated they would report any suspected abuse to the manager or to social services. A copy of the Rotherham local authority adult protection policies and procedures were available and accessible to staff, however a copy of the Barnsley local authority procedures were not. A detailed complaints log was available, there were no recent complaints recorded. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 19, 21, 24 and 26 Areas of the home accessible to residents were in the main well maintained, however the main kitchen is still in need of upgrading. Sufficient bathing facilities were not provided. Resident’s rooms were personalised and in the main well decorated, however some first floor bedrooms had water damage to the walls and ceilings, and one room had a damaged chair, which was unsafe. The home was clean, pleasant and hygienic. EVIDENCE: In the main the home was clean, well decorated and well maintained. The ongoing requirement to upgrade kitchen ventilation system and replace the defective kitchen units and worktops had not been made, leaving the food preparation area unsafe. The floor tiles in the kitchen were cracked and staff reported that they are slippery, compromising the safety of staff working and entering the kitchen. There was a hole in the wall at the entrance to the lounge on the first floor, where the plaster was cracked and crumbling.
Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 15 The home does not provide sufficient bathing facilities; the previous requirement to replace the bathing facility in the first floor had not been met. In the main bedrooms were well decorated and well furnished. Residents and relatives stated that they were happy with their bedrooms and that they had everything they needed, maximising their comfort. Some bedrooms had sustained water damage to the ceiling and walls following a roof leak. One bedroom had a damaged chair, which was unsafe. Some resident’s rooms did not have light shades and in one room an electrical switch was cracked and had been taped up. Residents and relatives stated that the home was clean, residents were happy with the laundry service provided. Policies and procedures were in place for control of infection, some staff had received training and staff reported that they had sufficient provision of protective clothing. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 An assessment of the current staffing levels is needed to ensure residents are safe and all their needs are met. Some staff are NVQ level 2 qualified and others are currently undertaking NVQ level 2 qualification. A robust recruitment procedure was in place, protecting residents. Staff had received some induction training. EVIDENCE: On the morning of the inspection there was one senior care assistant and one care assistant on the ground floor and one care assistant on the first floor, leaving times when residents were left unsupervised, compromising their safety. There were also kitchen staff, domestic staff, the handyman and the administrator on duty. Some staff stated that there was sufficient staff on duty to meet the needs of the residents; other staff stated that if there were more staff on duty the staff could do more with the residents. One resident stated that there was not always enough staff on duty. Three staff files had detailed recruitment information including two written references, a CRB disclosure and a copy of terms and conditions, the operations manager stated that a risk assessment was carried out with staff if a CRB disclosure had a positive outcome, protecting residents. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 17 The administrator stated that four staff had completed NVQ level 2, and other staff were in the process of completing the award. Staff stated that they had received induction training, which included health and safety training and shadowing more experienced staff. One member of staff spoken to had not had fire training since commencing employment at the home. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, and 38 In the absence of the manager adequate support is being given to staff. A procedure on the handling of resident’s money should be available and two signatures for financial transactions on behalf of residents should be implemented to safeguard their interests. Residents and relatives feel that the home is safe, however all staff need fire and moving and handling training to improve the level of safety for residents. EVIDENCE: The manager is currently absent from the home due to sickness, the manager from another home within the organisation is visiting regularly and the operations manager is visiting weekly. The administrator stated that she feels well supported in the absence of the manager, as support is always available by telephone. The administrator stated that the manager had completed the NVQ level 4. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 19 Records were available for residents whose money is in the safe. These included written records of every transaction with receipts for goods bought from outside the home. Residents financial interests are not fully safeguarded as one person signs the majority of transactions and the procedure for the handling of resident’s money was not available; the administrator contacted the operations manager who stated that the procedure was not available as it was being reviewed at the present time. Resident’s money is reconciled monthly by the administrator and six monthly by a representative from the organisation. Some staff spoken to stated that they received regularly training however some had not received fire training or manual handling training. Maintenance records were very thorough and checks on fire equipment, water temperatures and other safety checks were carried out, protecting the health safety and welfare of residents and staff. Water temperature checks highlighted unsafe water temperatures in one resident’s room, when this was checked the hot water supply had been turned off. Hot water temperatures in other areas was safe at around 43 degrees centigrade. All the required servicing of systems and equipment had been carried out or was planned in the near future. The door to the fire escape on the first floor was locked, staff can open the door with a master key, but this could delay any evacuation. However it would be unsafe to leave the door unlocked as it leads directly onto a stairway and there would be a high risk of residents falling. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 2 x 1 x x 2 x 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x x x 2 x x 2 Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 21 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. 3. 4. Standard 2 9 12 18 Regulation 5 13 16 13 Requirement All residents must have a written contract. Records for the receipt and administration of medication must be clear and complete. Residents must be consulted about activities and outings they wish to participate in A copy of the Barnsley Local Authority Adult Protection policies and procedures must be available. 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 wall near the entrance to the first floor lounge must be repaired. The first floor bathing facility must be replaced (Previous Timescale of 30/12/04 not met). The rooms which have sustained water damage must be decorated All residents rooms must have a lightshade The damaged chair must be
J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Timescale for action 30/06/05 31/05/05 31/07/05 31/07/05 5. 6. 19 19 23 23 31/07/05 31/07/05 7. 8. 9. 10. 11. 19 21 24 24 24 23 23 23 13 13 31/07/05 31/05/05 31/07/05 30/06/05 30/06/05
Page 22 Manor Court Version 1.20 replaced. 12. 13. 24 27 13 18 The identified electric switch must be repaired or replaced. An assessment of the current staffing levels must be carried out to ensure adequate numbers of staff are available, to maintain residents safety and their needs are met. Two signatures must be included on residents personal money accounts, wherever possible one of these must be the resident. A procedure for the handling of residents money must be in place. All staff must receive fire and moving and handling training A risk assessment of the means of escape from the first floor in an emegency must be carried out with the fire officer and the appropriate action taken to ensure the safety of residents All residents rooms must have a hot water supply maintained at a temperature of around 43 degrees centigrade. 30/05/05 30/05/05 14. 35 16 30/05/05 15. 16. 17. 35 38 38 16 23 23 30/05/05 30/06/05 30/06/05 18. 38 23 30/05/05 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. Refer to Standard 28 Good Practice Recommendations Fifty percent of care staff to be trained to NVQ level 2 or equivalent by 2005. Manor Court J51 S18271 Manor Court V218830 27.04.05 UI Stage 4.doc Version 1.20 Page 23 Commission for Social Care Inspection 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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