Inspection on 03/09/07 for Manor Farm

This inspection was carried out on 3rd September 2007.

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 24/04/06

Manor Farm 18/10/05

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 Ann Catterick Unannounced Inspection 3rd September 2007 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.V350093.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V350093.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Farm Address Hill Road Ingoldsthorpe Kings Lynn Norfolk PE31 6NZ 01485 541977 01485 544325 carl.harris@thedrivecarehomesltd.org.uk 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 Old age, not falling within any other category registration, with number (17) of places Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th April 2006 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. Information regarding this service is available in the entrance hall. The range of fees as stated by the Manager on 31 March 2006 is £268 - £500 a week. Additional charges include newspapers, telephone and transport; hairdressing at £5 - £17.50 and Chiropody £8. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and the site visit was on the 3rd of September and lasted for 7 hours. Prior to the inspection we received a annual quality assurance assessment that informed us on what the home feels it does well, what they think they could do better and what plans for improvement there are for the coming year. We received one comment card from a resident and one comment card from a relative at the time of writing the report. All written comments were positive. On the day of the site visit we were able to speak with residents, staff and management, inspect care plans, staff files and policies as well as have a tour of the building. Those residents spoken to were satisfied with their care and the overall quality of care was good. Comments made by residents “Food is good.” “Staff pretty good.” “I don’t get out much.” “No entertainment.” “Have to entertain yourself.” “Staff are kind, everyone of them.” Comments made by staff “Happy home.” “Would be happy for my nearest and dearest to live here.” “Would always report poor practice.” “We have enough staff on duty.” “Would like to complete my NVQ level 3.” “Good relationship with residents but not enough entertainment.” “Stable staff group.” What the service does well: The environment is comfortable and well cared for with a homely atmosphere. Staff are committed to providing good quality care to residents. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 6 Residents spoke very positively about the staff that work in the home. The food in the home is well presented and nourishing. What has improved since the last inspection? What they could do better: All care staff should be supported in achieving NVQ level 2 or its equivalent. More opportunity for activity and the following of leisure pursuits could be made. A quality assurance system needs to be put in place. Only residents who choose to share a bedroom should be doing so. Please contact the provider for advice of actions taken in response to this Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 8 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.V350093.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living in the home can be assured that their needs will be assessed prior to admission. This should ensure that if admitted their identified needs and preferences would be met. EVIDENCE: The manager would visit a prospective resident to assess their needs prior to admission. For those residents who are supported in their placement by social services a report from them would also be obtained. On the day of inspection those residents living in the home were having their assessed needs met. In care plans an assessment tick list was seen at the front of the file to ensure all the necessary information that is needed prior to and immediately after admission is collated. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 10 Signed contracts were seen in residents’ files. The home does not offer intermediate care. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living in the home can expect to have plans of their care that include their personal and health needs and how these can be met. They can expect that staff will treat them in a way that promotes their privacy and dignity. EVIDENCE: Several care plans were seen and these were adequate. The format is good but the manager must ensure that care plans are fully completed and updated on a regular basis. Some of the information with regard life history and leisure preferences was limited. A recommendation has been made in this area. The home has a good relationship with the local heath professionals and those residents living in the home were having their health needs met. The storage and administration of medication was inspected and this was generally in good order. It was noted that in the empty/used dossette boxes, waiting to be returned to the pharmacy, there was some unused medication. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 12 These dossette boxes were not locked in the medication cupboard, as is usually the case. A requirement has been made in this area. On the day of inspection staff were seen to care for residents in a way that promoted privacy and promoted dignity. When talking with staff they gave examples of how they treated residents in a respectful and thoughtful manner. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living in the home can expect to be offered some entertainment and that staff can spend some time with them on a one to one basis. Their visitors will always be welcome. The food provided will be of good quality and served in a dining area that is attractive and well presented. This should mean that residents are generally satisfied with their daily life but would benefit from further person centred activity. EVIDENCE: On the day of inspection there were only eleven residents living in the home. As this is a relatively small home staff are able to relate well with individuals and get to know individual needs and preferences with regard activity and occupation. Despite this, there is not very much that goes on in the home and when looking at entertainment records it often recorded ‘resting in the lounge.’ It was noted that a singing group attend once a month. This is fine if this is the residents choice but it was felt that there might be more opportunity to Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 14 spend time being involved with residents on a one to one basis to meet individual preferences. Comments made by residents were, “Don’t get out much.” “Not much entertainment.” “Have to entertain yourself.” A recommendation has been made in this area. The home is quite isolated and access to a mini bus would give those residents without family the opportunity to have some time away from the home. A recommendation has been made in this area. Visitors are always made welcome within the home. Residents are encouraged to be as independent as possible. If residents choose to look after their own money they are able to do so. The inspector was present at lunchtime and the meal provided was well presented and appetising. The dining area is light and airy offering a comfortable place in which to eat. Those residents that chose to have alcohol with their lunch were able to do so. For some, lunchtime was clearly seen as a positive social occasion. Residents can have an alternative to the main meal if they choose to do so but a second cooked choice is not automatically on the menu. A recommendation has been made in this area. Those residents spoken with were positive about the meals they received. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Residents living in the home can expect to have easy access to the complaints procedures and for any complaints to be taken seriously. Staff are given training needed to promote good practice and to protect service users from abuse. EVIDENCE: The home has a complaints procedure that is made available at the front of the home and is part of the Service User Guide. Those residents spoken to had no complaints but said they would speak to the manager or senior member of staff it they needed to. The one comment card received from a relative noted that the relative was aware of the complaints procedure and how to make a complaint. No complaints had been made since the last inspection. Staff receive some training with regard safeguarding adults in their induction and more formal training takes place following their probationary period. All of those staff spoken to said that they would report poor practice and were aware of the whistle blowing policy. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25 and 26 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Residents living in the home can expect to be living in a comfortable, well maintained environment that meets their needs. EVIDENCE: The home is well maintained and provides comfortable accommodation. The home has a gardener and handyperson to keep the garden well maintained and the home well cared for. The communal areas are plentiful including two large lounges, a dining area with conservatory attached. These areas are all well maintained although one lounge would benefit from some new lounge chairs. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 17 The gardens are attractive and make another communal area for residents to sit although access is not easy for the less mobile residents. A recommendation has been made in this area. Single bedrooms are large and well furnished with residents being satisfied with their private accommodation. Two residents were sharing a room and within the daily records it was noted that one of these residents was disturbing the other resident during the night. Residents should only share if they choose to do so and this area needs to be addressed. A requirement has been made in this area. Since the last inspection all bedroom doors have been fitted with the appropriate locks. The radiator near the kitchen is no longer functional and will be removed when the new fire door is fitted. On the day of inspection the home was well maintained, clean, tidy and free from any offensive odour. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Residents living in the home can expect to be supported by staff who are caring and happy in their role who have usually been offered the training needed to fulfil their role. All staff working in the home have been through a thorough recruitment process to ensure they are competent and safe to work in the home. EVIDENCE: The rota was inspected and showed that there are enough experienced and competent staff on duty at any on time to meet need. On the day of inspection there were only 11 residents living in the home and the manager, 2 care staff, a cook, a domestic, a gardener and handyperson on duty. The gardener and cook have mixed roles with the cook also being a senior carer and the gardener sometimes working in the kitchen. The home is small and this appeared to have no negative impact on the home. All residents spoke very positively about the staff saying they were hardworking and caring. The home does not have 50 of staff with NVQ level 2. Some staff are in the process of completing their NVQ level 2. Other staff are wanting to complete training but say this is not always forthcoming. The proprietor is required to Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 19 ensure staff receive the appropriate training. A requirement has been made in this area. Recruitment processes were seen and were adequate. The application form was limited giving little opportunity for the applicant to say why they wanted the job and what they could offer. A recommendation has been made in this area. Evidence of CRB checks, references being taken up and job descriptions given were seen on file. Staff receive induction training and evidence of this was seen on the day of the site visit. All of those staff spoken to felt that this was a caring happy home and said they would be happy for their nearest and dearest to live there. They said that there was a good staff team and a supportive manager. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Residents living in the home can expect the home to be well managed with policies and procedures in place to minimise risk and promote safe practice. The home does not have a system for monitoring the service provided and has been required to do so. EVIDENCE: The manager has his NVQ level 4 in care and has almost completed the Registered Manager Award with only one component left to do. The manager is well supported by a senior team and staff felt well supported by the manager. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 21 The home continues not to have a quality assurance system as the company intends to put a company system in place. This is not acceptable and the manager was advised to quality assure the service himself and consider ways he can publish the findings. A requirement has been made in this area. Some residents’ money is looked after by the home and the inspector audited three lots of money. Storage and recording of this was seen and good practice was taking place. Staff receive formal supervision on a regular basis and evidence of this was seen in staff files. A risk assessment of the environment was seen. Incident and accidents are recorded and then put on individual files. It would be good practice for auditing purposes to have a general file of copies of these as part of the quality system. A recommendation has been made in this area. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x 2 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x 3 3 x 3 Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13.2 Requirement Timescale for action 01/10/07 2. OP23 23.e 3. OP28 18 The manager must ensure that all medication is always stored safely. This relates particularly to any medication that may be in the used dossette boxes awaiting return to the pharmacy. The manager must ensure that if 01/10/07 two residents share a room they are both happy to do so. If this is not the case an alternative must be found. The registered manager must 01/01/08 ensure staff receive training appropriate to the work they are to perform. Previous timescales of 30/09/06 and 31/05/07 not met. The registered provider must ensure that a system of quality assurance is implemented. This must include systems for reviewing and improving the quality of care, including consulting with residents and their relatives and producing a report on any review carried out (to be supplied to the Commission and made available DS0000042229.V350093.R01.S.doc 4. OP33 24 01/01/08 Manor Farm Version 5.2 Page 24 to residents). Previous timescales of 31/07/06 and 31/01/07 not met. 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 OP7 OP12 OP12 OP15 OP19 OP27 OP38 Good Practice Recommendations It would be good practice if the care plans reflect the resident’s previous life history and lifestyle It would be good practice that more consideration is given to entertainment and activity within the home. It would be helpful if the company mini bus was sometimes at the home for residents to use. It would be good practice to have a formal second choice at lunchtime. It would benefit residents if they had easy access to the gardens. It would be good practice to include in the application form a section that gives new recruits opportunity to say what they could offer to the role. It would be good practice to collate accident information to enable good audit of incidents and accidents. Manor Farm DS0000042229.V350093.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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