CARE HOME ADULTS 18-65
Manor Court 72 Church Street Market Deeping Lincs PE6 8AL Lead Inspector
Alison Marshall Unannounced 28 July 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Manor Court Address 72 Church Street Market Deeping Lincs PE6 8AL 01778 344291 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) Sense East Mr Mitchell Bixley PC Care Home Only 5 Category(ies) of SI - Sensory Impairment - 5 registration, with number LD - Learning Disability - 0 of places Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23 May 2005 Brief Description of the Service: Manor Court 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 between the ages of eighteen and sixty-four who have been affected by deaf/blindness caused by rubella. 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 multisensory room and administrative offices. Service users attend a day care facility in Peterborough 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 C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was carried out between 9.30 am and 3.00 pm. Time was spent talking with the deputy manager, the staff on duty and looking at records. One service user was at home due to being unwell. A second service user was on a home day and spent most of the day out with staff support in the community. The three other service users were attending a day centre. The inspection focused on records and discussion with staff. The next inspection will be made at a time when service users will be present. This was a positive inspection with only a number of recommendations being made. What the service does well: What has improved since the last inspection?
All requirements following the last inspection had been addressed. Health and safety training had taken place with regards to medication administration and fire drills. Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 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. Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed. The service users had all lived at Manor Court for a number of years: the ‘newest’ service user having been there for over 4 years. EVIDENCE: Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Service user individual needs were promoted and documented appropriately. EVIDENCE: All service users had individual files and plans that were stored in the office. The files and plans were clear and well organised. The care plan file contained all of the working documents: the care plan itself with targets set in areas such as self help, making choices, leisure activities and communication; the pen picture was an assessment of the individual’s level of functioning in all areas of life; functional assessments of hearing and vision and behaviour management guidelines were clear and detailed as was the communication profile. All individual documents had been recently updated following the annual review. Other files contained records relating to health and finance and general correspondence. A communication log for each individual contained daily written logs and activity logs. The folder in which these were contained went back and forth between Manor Court and the day centre and so provided a 24 hour record of the individual service user. Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 10 From the records and discussion with staff it was apparent that service users were encouraged to make as many decisions for themselves as possible. Having returned from the day centre staff supported service users to plan their evening though the use of ‘icon books’ (symbols that represented activities and choices). Staff supported service users to take as much responsibility as possible for daily domestic chores. Each service user had a risk assessment folder containing detailed individual risk assessments. These were up to date and had been reviewed recently. Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17 Service users had busy and varied lifestyles with opportunities to engage in a range of educational, vocational and leisure activities. EVIDENCE: Records and discussion with staff showed that service users participated in a range of individual and group activities within the local community. These included yoga, trampolining, swimming, climbing, bicycle rides, shopping for food and clothes and visiting the local pub. All service users went on an annual holiday together. The group had recently returned from a week in Wales on a narrow boat. Staff explained that they used icons to assist service users to choose what sort of a holiday they wanted. The deputy edited video recordings and photographs of the holiday onto a DVD so that service users could watch them. Past holidays and outings had also been put on to videos or DVDs for service users. Service users attended the Sense day centre or had dedicated home days. On home days staff would support service users on a 1:1 basis. These days could be used for a number of different activities decided upon the individual.
Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 12 Within in the house service users undertook most of the domestic chores, individually and for the group, with staff support. Each person had a day on which they shopped for, prepared and cooked the evening meal. The menus were drawn up in advance and on the day the person chose one of two options to cook. Each service user had their own ‘snack box’. Staff encouraged healthy eating through assisting with menu planning and food shopping. Family members were encouraged to visit at any reasonable time. Service users were supported to maintain contact through visits, telephone calls and letters. Staff provided appropriate guidance and support to service users with regards to personal relationships to ensure they had sufficient information on which to make safe choices. Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Service users received personal and health care in line with their needs and independence in all areas was encouraged. EVIDENCE: Each service user had an individual health file. These were clear and well organised and showed that service users had appropriate input from a number of health agencies. Records showed regular visits to the GP, dentist and optician. Care plans detailed the support required by individuals in terms of their personal care. Medication records and storage were satisfactory ensuring that all medication was administered safely and correctly. The pharmacist visited every three months. At the last visit the pharmacist report showed that administration records were good and storage and stock control was good. Although there was information regarding the administration of individual PRN medication it was not always up to date as other information in the main health file. Only staff that had received training administered medication. Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 There were good systems in place to ensure the safety of service users. EVIDENCE: There had been no complaints made since the last inspection. Adult protection was covered within staff induction training and staff spoken with were aware of the policy and procedure although the procedure had never had to be initiated. The management were aware that this was an area that needed to be readdressed to keep it in the forefront of staffs’ minds. As a result, the deputy manager said that adult protection was going to be included as a discussion point in forthcoming staff appraisals. Sense had a dedicated behaviour advisor to support staff and service users in managing behaviour. Each service user had an individual behaviour management plan that detailed the behaviours, gave possible reasons behind the behaviours, precursors, triggers and de-escalation strategies. The guidelines were reviewed regularly. All incidents of behaviour and the use of physical intervention were recorded. The records were signed by the manager and sent to the behaviour advisor who monitored them. Copies of the records were also kept on individual files. Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 Manor court was generally well decorated and maintained. EVIDENCE: A tour of the premises showed that the Manor Court was generally well maintained and decorated. The home looked clean and tidy and no unpleasant smells were noticed. Individual service user bedrooms were not seen as service users were out and not able to give permission for them to be seen. There have been no concerns raised about the condition of bedrooms in past reports. Records and discussion with staff showed that service users were choosing new belongings and decoration for their rooms. Following the last inspection work had started on the shower room to remove the lip to the shower to improve access. However, the new flooring had not been laid at the correct angle and so water was running across the floor towards the door. This was being addressed and it was anticipated that it would be resolved in the near future. Laundry facilities were situated in a building separate to the main part of the home. The facilities included a washing machine with sluice function and tumble dryer.
Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35 and 36 Service users were well supported by a small competent dedicated staff team ensuring consistency in practice and support. EVIDENCE: There were a couple of part time vacancies created by previous employees leaving unexpectedly and quickly. This combined with annual leave and staff sickness meant that the staffing rotas for the week of the inspection showed staff shortages. On one late shift there had only been two staff on duty after 6pm. The deputy explained that this was a very unusual situation and past rotas confirmed this. Staff spoken to also confirmed that staffing levels were also usually very good and allowed for plenty of activity to take place in the evening. An open recruitment evening had recently been held and interviews were planned for the near future. Staff were very positive about the induction they had received and the ongoing training opportunities. Training had been provided in terms of meeting the specific needs of the service user group. Staff used icons and icon books to support service users with making choices and planning their days. It is recommended that further training is sought to enable service users to work towards using the icons independently and initiating their use rather than staff making the decision as to when to use them.
Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 17 Staff confirmed that they received regular supervision and annual appraisals and that these were recorded in writing. Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 and 40 Manor Court was well managed and the management team was open and approachable. EVIDENCE: Staff were positive about the management team and the staff team describing them as open and supportive. They felt that this enabled them to support service users in new and varied activities. Sense had a full range of policies and procedures in place that were available in hard copy and also on the intranet on the computer in the office. The index of policies showed that a number of policies were in need of urgent review. Some of these had been addressed and were out in draft but ongoing work was needed to ensure that all policies were brought up to date. Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Manor Court Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 x 3 x x x C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 20 NO 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. 1. Standard NA 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. 3. 4. 5. 6. 7. Refer to Standard 10 13 20 23 24 32 33 Good Practice Recommendations The registered person should consider what sort of information is recorded on the whiteboard in the kitchen. The registered person should ensure that the system for service users payment for transport is equitable according to the usage and benefit that individuals derive from it. The reigstered person should ensure that the PRN guidelines in the medication folder reflect the most up to date information. The registered person should ensure that wording on incident forms is factual only. The registered person should ensure that the work on the shower is completed as soon as possible. The registered person should consider offering training to staff with regards to the icon system to enable service users to use it independently of staff. The registered person should ensure that staffing levels are maintained at all times. Manor Court C04 C53 S2452 Manor Court V240071 28-7-05 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Unity House, The Point Weaver Road, off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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