Inspection on 14/12/05 for Manor Gate

This inspection was carried out on 14th December 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 Gate 03/11/08

Manor Gate 06/05/08

Manor Gate 23/05/07

Manor Gate 30/05/06

Manor Gate 17/08/05

Manor Gate 10/11/04

Manor Gate 15/06/04

Similar services:

Carlton Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Manor Gate 190 Causeway Wyberton Lincs PE21 7AR Lead Inspector Julie Western Unannounced Inspection 13th December 2005 09:30 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 Gate DS0000002380.V273117.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 Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manor Gate Address 190 Causeway Wyberton Lincs PE21 7AR 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) 01205 366260 Mrs Mary T Rodrigues Mr Herman V Rodrigues Mr Herman V Rodrigues Care Home 15 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (14), of places Physical disability (1) Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One PD place for age 59 . Date of last inspection 17th August 2005 Brief Description of the Service: Manor Gate Care Home is a converted Victorian farmhouse with a purpose-built annexe, situated in the village of Wyberton, close to local shops and approximately one and a half miles from the market town of Boston. It is registered to provide care and accommodation for up to fifteen residents over the age of 65 years, some within the category of dementia and one under 65 years, in two shared and eleven single rooms. On the day of the inspection there were fourteen residents. The home also has three day-care places but these were not in use. There is a garden to the side of the property and car parking space for four cars; further parking is outside the frontage of the home. This is a family-run home, run by the proprietor Mr. Herman Rodrigues, his son Lawrence, who manages the home on a daily basis, his wife who works in the home in a senior care role and Lawrences wife, who also works as a carer. Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 3 ½ hours. A partial tour of the building took place and care records were inspected. The main method of inspection used was called ‘case-tracking’; this involved selecting four residents and tracking the care they received through the checking of their records, discussion with the residents and care staff and observation of practices. Some policies and procedures were examined and records concerning the safety of the home were also seen. Three of the fourteen residents, two of the care staff and three visitors were spoken with. The Assistant Manager was present throughout and the owners were present for part of the inspection. What the service does well: What has improved since the last inspection? The on-going refurbishment of the home has continued with two more rooms having been upgraded. The walls below the dado area in the hall and dining room have been repaired and the dining room has been redecorated. The lounge is in the process of redecoration. There is now a calendar of activities. The home has also purchased a new mobile hoist. The gardens have been tidied. Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 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 Gate DS0000002380.V273117.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 Gate DS0000002380.V273117.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): 1-5 The home clearly sets out what it intends to do for its residents and this information is freely available to residents. A comprehensive initial assessment ensures that the needs of residents can be met. Prospective residents are encouraged to take time before making the decision to move into the home on a permanent basis. EVIDENCE: There is a comprehensive statement of purpose that tells the service user and their relatives what they can expect from the service and that there will be an assessment process to undertake prior to a service being provided. The service user guide is available in a clear and easily understood format. The Assistant Manager said that he usually carried out pre-admission assessments and he demonstrated a good knowledge of mental health issues during the inspection. Records showed that each resident received a detailed statement of their terms and conditions. A visitor spoken with confirmed that her relative had visited the home before moving in permanently. Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 The home’s records give a clear picture of the needs of residents, although there is no information on how to manage the behaviours of some residents. Staff members are able to meet the needs of residents with sensitivity and regard for their privacy and dignity. Staff members are trained in the safe handling of medication and in palliative care and bereavement, ensuring that residents are safely cared for. EVIDENCE: The four care plans looked at in depth contained clear initial assessments and care plans and were reviewed regularly. The care plans for some residents with identified behaviours did not include information on how to identify triggers or how to manage these behaviours. There was a clear medication policy and the pharmacist visited regularly; his last report, on 5/7/05 had no issues of concern. The assistant Manager confirmed that only trained staff members were able to administer medication. Residents said they felt safe and well looked after; one said ‘I can’t fault them’. The staff team were observed carrying out their duties with kindness and sensitivity towards the residents, especially when attending to their personal needs. The Assistant Manager said that all staff had recently attended a course on Palliative Care and Bereavement’. Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 10 A visiting District Nurse who had been visiting the home regularly for five years, said that the standard of care at the home was good and that the staff group managed the needs of the residents very well, with a very good understanding of residents with dementia. She did, however, comment that communication between day and night staff had not always been clear in the past; this was relayed to the owner and Assistant Manager, who said that new night staff had been employed recently. Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Social activities create a variety of events and activities, which residents are informed about. The home would still benefit from having a designated member of staff responsible for the co-ordination of activities and the production of a Newsletter to inform residents and visitors of events. The residents exercise choice about which activities, if any, they wish to participate in and what meals they want to eat. EVIDENCE: The activities calendar showed that the activities provided by the home, included film shows, Bingo, coffee mornings, music and outside entertainment. On the day of the inspection the annual Christmas tea party was being held and visitors were coming and going throughout the morning with presents and items for the party. Recent events included lunch at a local pub and this week eight residents were going to a local garden centre for the day, including lunch. Activities were recorded in a notebook, but it was noted that there was still no one responsible for co-ordinating the programme of activities and many daily activities, such as visits from local dogs and their owners or the church representatives were not recorded at all, although residents said they happened regularly. Residents spoken with enjoyed the meals served at the home and all said they had a choice for both the main meal and for tea. The mid-day meal was seen to be balanced and nutritious, with fresh vegetables. Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 The home’s complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to; there is a robust adult protection procedure. EVIDENCE: Residents said they did not wish to complain but knew how to make a complaint. The home had received no complaints in the last twelve months. There was a clear adult protection policy, which was linked to the Local Authority Adult Protection Procedures. Two staff members spoken with had recently received training on adult protection. Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,23,25,26 The residents live in a comfortable, pleasant and safe environment with both private and communal space being on the whole suitable for their needs. EVIDENCE: Overall, the standard of decoration internally was good and afforded residents a great degree of comfort, although the main lounge was cold and one resident was complaining of the cold; the owners took immediate action by turning up the radiator in that room. The home was clean and tidy and smelled fresh throughout. The Assistant Manager was responsible for the rolling maintenance programme and had a notebook into which matters needing attention were entered and ticked off when completed. Recent renovation included the walls below the dado area in the hall and the dining room has been redecorated; the lounge is in the process of being redecorated. Residents’ rooms were comfortable and well furnished. The laundry room had not been renovated as the owners are developing plans to extend the home, which will include the provision of a new laundry. There was evidence of specialist equipment Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 14 including raised toilet seats and grab rails and the home has recently purchased a mobile hoist. Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected EVIDENCE: Although these standards were not fully inspected, the staff rota showed that there were enough staff numbers according to the staffing matrix and shifts were staggered to accommodate the needs of residents; residents, visitors and staff thought there were enough staff members on duty to complete their tasks. Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,38 The home is managed competently and the staff are supported and supervised in carrying out their respective roles. The views of residents are listened to and they are involved where possible in decisions affecting them. EVIDENCE: The current owner is also the Registered Manager; his son Lawrence has recently taken over much of the day-to-day management of the home and is working towards the NVQ Managers and Care Awards with a view to becoming registered Manager. Staff interviewed said they felt supported by the management of the home and they were approachable and accessible. Quality assurance was achieved by questionnaires being given to residents and sent out to relatives/advocates with invoices. Staff meetings were held regularly. Those policies and procedures seen were up to date. Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 17 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 18 3 3 X X 3 3 X 3 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X X X 3 Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 18 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] 13[4] Requirement The registered person must include all aspects of the health, personal and social care needs in the service user’s care plan. This should include the triggers to behaviours and how to manage these. The registered person must ensure that the stimulation offered through leisure and recreational activities is suited to the needs of the residents and that up to date information about activities is circulated. The registered person must make repairs to the following areas: 2] the laundry room This is outstanding from the previous report. The owners must forward plans for the extension which will include a new laundry room. Timescale for action 08/02/06 2. OP12 16[2] 12[4] 08/02/06 3. OP19 23[2][b] 31/03/06 Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 19 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 OP15 Good Practice Recommendations It is a recommendation that the day’s menu [complete with date] is displayed near to the dining room for residents to read. Manor Gate DS0000002380.V273117.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Lincoln Area Office 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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