Inspection on 18/10/05 for Manor Farm

This inspection was carried out on 18th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Manor Farm 03/09/07

Manor Farm 24/04/06

Manor Farm 06/05/05

Manor Farm 23/09/04

Manor Farm 29/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Manor Farm Hill Road Ingoldsthorpe Kings Lynn Norfolk PE31 6NZ Lead Inspector Mrs Jacky Vugler Unannounced Inspection 18th October 2005 09:15 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 Farm DS0000042229.V249360.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 Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manor Farm Address Hill Road Ingoldsthorpe Kings Lynn Norfolk PE31 6NZ 01485 541977 01485 544325 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) The Drive Care Homes Ltd Carl Anthony Harris Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (17) Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th May 2005 Brief Description of the Service: Manor Farm House is a large detached building situated on the edge of the small rural village of Ingoldisthorpe. There is parking to the front and side of the home with attractive gardens to the rear of the Home. Ingoldisthorpe has few local facilities but the towns of Hunstanton and Kings Lynn are both a short drive away. The home provides care for up to seventeen elderly people. In May 2003 the home was purchased by an organisation known as The Drive Care Homes Ltd. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection taking place over eight hours on a weekday. Mr Carl Harris, the Manager, was present during the inspection. Preparation for the inspection had taken place at the CSCI office. There were thirteen residents accommodated on the day. Several records were viewed, and three residents and a member of staff were spoken to privately. Six comment cards from residents and seven from relatives were received prior to the inspection. These spoke highly of the staff and a few commented on the lack of activities and outings. What the service does well: What has improved since the last inspection? What they could do better: Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 6 The care plans need clearer guidance to staff about how to meet the needs of the residents and risk assessments need to be improved. The full care plans should be signed by the residents and made accessible to staff. It is also recommended that the care plans reflect the resident’s previous lifestyle. Although a complaints form is kept in residents’ care plans, these are not very accessible. It is therefore recommended that copies of the complaints form be made available to residents, visitors and staff. This form could also include comments and suggestions. Although the organisation carry out unannounced visits, these need to be monthly in order to be confident that any difficulties are highlighted and can be addressed adequately. 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 Farm DS0000042229.V249360.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 Farm DS0000042229.V249360.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): 3 and 6 Prospective residents have their needs assessed before they are admitted. They and their families are able to visit the home to enable them to assess the quality of the home. The home does not provide intermediate care. EVIDENCE: The Manager and Senior Care assistant visit prospective residents prior to admission, and at this point they complete an assessment. On admission the residents family or representative are also asked to complete a questionnaire. This includes personal preferences and any hobbies or activities, and is signed by the resident. All this information forms the basis of the care plan. One resident spoken to said that before admission she visited the home a few times and stayed at the home for two days to see if she liked it. Written information from the Social Workers was seen held in files. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 9 It is recommended that these documents, which are currently stored in the Manager’s office, be kept as part of the care plans and accessible to staff. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 10 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 The home cannot be sure that they are able to meet needs as the care plans are not detailed enough and the complete versions are not available to staff. The storage of medications has improved, and this promotes good health. EVIDENCE: Three care plans were looked at. The initial assessment, risk assessments and care plan reviews are stored in a locked cupboard in the manager’s office. Staff do not have access to these, instead, they have access to copies of the care plans, which are based on this information. Although moving and handling assessments are completed for residents on admission, they are not available to staff. The care plans with regard to mobility were not detailed enough to provide adequate guidance to staff, particularly with regard to the use of the hoist. Risk assessments have not been undertaken for all necessary situations. The particular ones noted to be missing were concerning pain control and residents going out alone. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 11 It is therefore required that the care plans provide detailed guidance to staff with regard to meeting individual residents needs and that the plans are available to staff at all times. None of the care plans seen contained a life story of the residents. It is recommended that the resident or their representative sign the care plan. The medications were stored appropriately and records were well completed. All the requirements from the last report have been complied with. The resident who wishes to administer her own medicines has a risk assessment, has signed her consent, and has a locked drawer in her room in which to store them. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 12 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, 13 and 14 The home does not fully meet the social and recreational needs of residents. Residents are able to maintain contact with family and friends and to exercise choice and control over their lives. EVIDENCE: The residents’ hobbies and interests are recorded on the questionnaire completed on admission to the home. The feedback from comment cards mentioned the lack of activities and outings provided. It was suggested that the residents would enjoy shopping trips, for example, to do their own Christmas shopping. Another said “it would be nice to have someone read me the papers sometimes”. Few regular activities are provided except for a musician who entertains the residents monthly. The residents spoken to thought she was “very good”. The Manager said that trips out are difficult as the home does not have suitable transport, and to take the residents out in a wheelchair means that staff have difficulty pushing the wheelchair uphill back to the home. The Manager is trying to arrange for the Body Shop, Boots and a book club to visit Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 13 before Christmas so that residents, not able to go out, can choose their presents independently. One resident spoken with leads a very full life going out with friends. All residents spoken with commented on the choices available to them and said that staff treated them with respect. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 14 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): 16 and 18 The arrangements for protecting residents’ and responding to their concerns are in place but not readily available. EVIDENCE: The home has the complaints procedure displayed and copies of the complaints forms are in the care plans. These are not accessible to visitors and it is therefore recommended that they be made readily available, for example, at the entrance of the home. The manager keeps a register for complaints, although none are recorded in it. Staff have had training in the awareness of adult abuse and the Manager has devised an informative document, which the staff keep. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 15 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 and 26 A comfortable and safe standard of accommodation is provided for the residents. EVIDENCE: In general, the home is well maintained and suited to residents’ needs. Some improvements have taken place recently and these include the redecoration and re-carpeting of the hallway and two residents bedrooms. A bathroom has been refurbished and now contains a shower cubicle with seat. The drive is currently being re-gravelled. The residents’ bedrooms seen looked homely, as they had been able to bring items of furniture and possessions with them. All areas of the home smelled pleasant and were cleaned to a high standard. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Since the last inspection the staffing levels in the evenings, nights and early mornings have been addressed. There are now in sufficient numbers and skill mix to meet the needs of the current independent group of residents. The recruitment practices are satisfactory and offer protection to those living in the home. EVIDENCE: Since the last inspection the home employs two waking night staff. A senior carer and care assistant are on duty for the daytime hours. In addition, are cooking and domestic hours. The management of the home needs to constantly review dependency levels as if these increase this level of cover may not be sufficient especially at meal times. Comment cards from residents and relatives seem to differ in opinion on staffing levels; for example, ‘there seems to be a staff problem’, ‘the home is short staffed means that the carers don’t have the opportunity to give the residents any “quality time”’. However, others indicate there are no staffing problems. Many comments praised the staff saying they were “pleasant and helpful”, “we are always informed of any changes”, “staff are very kind”. No member of staff has achieved the NVQ qualification. The Manager said that some staff started last year, but then the company ceased. Another company is due to visit the home on 25 October 2005 regarding this training. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 17 The three staff files looked at during the inspection showed that the home had good recruitment practices. Staff had a personal development plan and training was undertaken to support staff in providing for the needs of the residents. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 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 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): 36 The staff are appropriately supervised by the Manager. EVIDENCE: Three staff files were looked at, two contained appropriate supervision records and one was a new member of staff who had her probation performance completed. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 3 x x Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 20 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 Standard OP7 Regulation 15 (1) Requirement The Registered Manager must ensure that the care plans contain detailed guidance for staff about how to meet individual needs and that the full plans be available to staff. (Previous timescale of 30.6.05 not met). The Registered Manager must ensure that risks are identified and adequately assessed. (Previous timescale of 30.6.05 not met). The organisation must carry out monthly unannounced visits and send a copy of the report to the Commission. (Previous timescale of 31.5.05 not met). Timescale for action 31/12/05 2 OP7 13 (4) 31/12/05 3 OP33 26 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Manor Farm Refer to Good Practice Recommendations DS0000042229.V249360.R01.S.doc Version 5.0 Page 21 1 2 3 4 Standard OP3 OP7 OP7 OP16 It is recommended that the pre care plan assessments be stored with the care plans. It is recommended that the care plans reflect the resident’s previous lifestyle. It is recommended that the resident or their representative sign the care plan. It is recommended that copies of the complaints form be made readily available to residents, visitors and staff. Manor Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 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 Farm DS0000042229.V249360.R01.S.doc Version 5.0 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!