Inspection on 30/05/06 for Manor Gate

This inspection was carried out on 30th May 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Manor Gate 03/11/08

Manor Gate 06/05/08

Manor Gate 23/05/07

Manor Gate 14/12/05

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 Key Unannounced Inspection 30th May 2006 09:00 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.V297283.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 Gate DS0000002380.V297283.R01.S.doc Version 5.2 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.V297283.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One PD place for age 59 . Date of last inspection 14th December 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 thirteen 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 is the assistant Manager and 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.V297283.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 3 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 three 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 thirteen residents, two of the care staff and two visitors were spoken with. The Assistant Manager was present throughout and one of the owners was present for part of the inspection What the service does well: What has improved since the last inspection? What they could do better: There is still a need for a formal post of activities co-ordinator working regular, dedicated hours. The management structure of the home is not currently clear; the registered manager is not in the home as often as he is gradually retiring and the assistant Manager is working towards the Manager’s Award and also is Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 Page 6 not always present. This has led some staff to feel that they are not always supported, particularly out of office hours. 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.V297283.R01.S.doc Version 5.2 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.V297283.R01.S.doc Version 5.2 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, 6 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. 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 Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 Page 9 terms and conditions. A visitor spoken with confirmed that his relative had visited the home before moving in permanently. Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 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): 7-10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The home’s records give a clear picture of the needs of 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, ensuring that residents are safely cared for. EVIDENCE: The three care plans looked at in depth contained clear initial assessments and care plans and were reviewed regularly. The care plans included assessments from other agencies such as social workers, Community Psychiatric Nurses and the hospital. There were body maps for some residents who were liable to fall. There was a clear medication policy and the pharmacist visited regularly; his last report, on 31/3/06 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 ‘they’re very helpful’ and all agreed that night care staff were also pleasant. The staff team were observed carrying out their duties with kindness and sensitivity towards Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 Page 11 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’. A visiting District Nurse said that the standard of care at the home was adequate and that the staff group managed the needs of the residents well, with a good understanding of residents with dementia. She did, however, comment that communication about one patient had been poor, with staff unaware of his medical needs. In discussions, the assistant Manager said that in this case, the home had not been given sufficient information by the relatives. Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 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): 12-15 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. The home has a programme of events and activities but there is still no designated member of staff responsible for the co-ordination of activities. 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 trips to Skegness, music and outside entertainment. On the day of the inspection residents were being entertained by an organist and were enjoying singing to the music. Activities were recorded on a calendar, but it was noted that there was still no one responsible for co-ordinating a programme of activities to include indoor group activities such as armchair exercises, painting, craftwork and games. The 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 and a menu board now displayed the day’s menu. Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home’s complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to; the adult protection procedure was not followed during a recent investigation. EVIDENCE: Residents said they did not wish to complain but knew how to make a complaint. The home had received one complaint in the last twelve months, which was still being investigated; the Local Authority Adult Protection Procedures had not been completely followed on this occasion. Two staff members spoken with had recently received training on adult protection. Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. The residents live in a comfortable, pleasant and safe environment with both private and communal space being on the whole suitable for their needs; some upgrading is needed, particularly with regard to the laundry. EVIDENCE: Overall, the standard of decoration externally was good. Internally, decoration was to a good standard and residents’ rooms were comfortable and well furnished. The home was clean and tidy but smelled fusty in some areas; the assistant Manager said he was looking into the provision of fragrance dispensers. 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. On the day of the inspection a visiting community nurse found that there was no hot water in one of the bedrooms. The laundry room was in need of refurbishment but the owners are developing Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 Page 15 plans to extend the home, which will include the provision of a new laundry. The toilets for communal use had towels; the assistant Manager said that this was because some residents blocked the toilet when paper towels were used; during discussions it was suggested that the provision of roller towels could be a solution to the possibility of cross-infection from towels. Some first floor windows needed restrictors. There was evidence of specialist equipment including raised toilet seats and grab rails throughout and a stair lift to the first floor. Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 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): 27-30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. There are sufficient numbers of appropriately trained staff to allow them to care for the residents, but not to allow for 1-1 activities; an activities coordinator is needed. Staff members are supported in carrying out their respective roles by training but there is no training plan. EVIDENCE: Although the staff rota showed that there were enough staff numbers according to the staffing matrix, some staff and residents felt that there could be more staff, particularly to address the recreational or 1-1 needs of this group of residents. There was no training plan and the assistant Manager acknowledged that this was a shortfall, which would be addressed in the near future. Staff spoken with said that the most recent training had been in basic care planning, basic food hygiene and fire. Four staff members had applied to undertake National Vocational Qualification training at Level 2 once funding had been arranged. Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 Page 17 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): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is managed competently but staff members do not always feel supported in the absence of management. 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; as he gradually retires, his son Lawrence is taking 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 but that they were sometimes difficult to contact, particularly out of hours. Quality assurance was achieved by questionnaires being given to residents and sent out to relatives/advocates with invoices. Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 Page 18 Staff meetings were held regularly. Those policies and procedures seen were up to date. Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 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 3 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 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 Page 20 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 OP12 Regulation 16[2] m,n Requirement The registered person must ensure that the stimulation offered through leisure and recreational activities is suited to the needs of the residents. This is outstanding from the previous inspection. The registered person must ensure that in the event of an adult protection issue, the Lincolnshire County Council’s Adult Protection procedures are followed accordingly. The registered person must address the following; 1] Residents should have access to a supply of hot water in their rooms. 2] The home should smell fresh. 3] The possibility of crossinfection from the use of hand towels in toilets must be looked into. 4] Windows at first floor level must be fitted with restrictors to prevent falls. Timescale for action 25/07/06 2. OP18 13[6] 25/07/06 3. OP26 23[2]b,d,j 25/07/06 Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 Page 21 4. OP27 18[1]a 5. OP31 18[c] The registered person must adjust the numbers of staff on duty according to the needs of the residents. The registered person must ensure that staff members are aware of the management structure and how to contact management in an emergency. 25/07/06 25/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Manor Gate DS0000002380.V297283.R01.S.doc Version 5.2 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. 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