Inspection on 14/07/05 for Manor Hall

This inspection was carried out on 14th July 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 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 Hall 12/04/10

Manor Hall 30/12/09

Manor Hall 03/03/08

Manor Hall 30/10/06

Manor Hall 13/12/05

Manor Hall 01/02/05

Manor Hall 29/07/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Manor Hall Borough Lane Eastbourne East Sussex BN20 8BB Lead Inspector Kathy Flynn Announced 14 July 2005 13.00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Manor Hall Address Borough Lane Eastbourne East Sussex BN20 8BB 01323 722665 01323 647804 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) South Coast Nursing Homes Limited Ms Louise Murtagh Care Home 38 Category(ies) of Physical disability (PD) 38 registration, with number Old age, not falling within any other category of places (OP) 38 Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of thirty-five (35) service users in receipt of nursing care and three (3) in receipt of personal care. 2. Residents must be older people aged sixty-five (65) years or over on admission. 3. Residents with physical disabilities under sixty-five years may be admitted. Date of last inspection 01.02.05 Brief Description of the Service: Manor Hall is registered to provde nursing care for up to thiry five residents and personal support for up to three residents. The home consists of two buildings linked by a corridor on the first floor with a driveway seperating the building on the ground floor. It has been converted and adapted for its present use and retains many of its original features. A shaft lift enables residents to have access to all parts of the home and a stair lift provides access to the lift in one part of the building. There is a large lounge with a dining area on the ground floor that is used by residents if they wish, with sufficient space for social activities and access to the patio area at the front of the home. Situated in a residential area it is close to local amenities and public transport with an attractive park nearby. Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There was some confusion concerning this inspection, the manager and staff are to be thanked for their assistance. The requirements from the previous inspection and the information provided in the pre-inspection questionnaire were used to develop a plan for this inspection. The aims were to assess if the home had met the requirements, identify the aspects of the service that had improved and how the service could be developed for the benefit of the residents. The inspection was carried out over six hours from 13.00pm and included an examination of care plans and personnel records as well as discussions with residents, relatives, visitors and staff. There were 34 residents at the home during the inspection, 32 requiring nursing care and 2 requiring personal support. 15 residents, relatives and visitors were happy to talk about the care provided, the manager and some of the staff on duty talked about their role in providing care and support at Manor Hall. What the service does well: What has improved since the last inspection? The requirements from the previous inspection have been met or partially addressed. The Statement of Purpose has been reviewed and combined with the information required in the Service Users Guide to produce detailed information about the services offered at the Manor Hall. Care plans are now reviewed on a regular basis, with the involvement of residents and their representatives. Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 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 Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 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 standard(s) 1, 3 and 5. Standard 6 is not applicable. The homes Statement of Purpose and Service User Guide are good providing residents and prospective residents with details of the services the home provides enabling an informed decision about admission to the home. An appropriate pre-admission assessment is used prior to the offer of a room to ensure the home can meet prospective residents needs. EVIDENCE: The Statement of Purpose and Service Users Guide have been reviewed, updated and combined to provide comprehensive information for residents, prospective residents and their relatives about the care and support offered at Manor Hall. Pre-admission assessments are completed for all prospective residents to ensure that the home can meet their needs. Prospective residents and their relatives are encouraged to visit the home and residents may move in on a trial basis before they decide to take a room on a permanent basis. Some residents explained that they had heard about Manor Hall from friends and relatives and they were happy to accept a room on that basis. Although Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 Page 9 their relatives came to the home to look at the rooms that are available before they accepted them. Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 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 standard(s) 7, 8 and 10. The care planning system is clear and consistent and provides staff with the information they need to satisfactorily meet residents’ needs. The staff have a good understanding of the residents support needs. This is clear from the positive relationships, which have been formed between the staff and residents. EVIDENCE: The care plans have been updated and show evidence of the involvement of residents and their relatives, if appropriate. The information available to staff is based on the pre-admission assessments and includes appropriate risk assessments, a daily record of the care provided and the needs of the residents as well as social histories, a relative is currently writing one for a resident. Residents are registered with GP’s and are referred to allied health professionals including physiotherapists and Tissue Viability Nurses if required. It was noted that the relationship between staff and residents is friendly and relaxed, residents are treated with respect and staff spend time in the lounge with the residents, including having their meals there. Residents said that staff are very supportive, with their privacy protected when they need help with personal care. Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15. The routines at the home are flexible this enables the residents to have control over their lives and encourages them to make choices about all aspects of their day to day living. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. EVIDENCE: Activities are provided for residents if they wish to participate. Weekly visits from a therapist encourage some residents to join in physical and mental exercises. Residents spoke positively about these and the monthly visits from the local non-denominational church group. Several residents prefer to spend their time in their own rooms or visiting other residents in theirs, they know that activities are provided in the lounge but they prefer to spend their time reading or watching TV. Residents are encouraged to make choices about all aspects of their lives and are supported if they wish to make changes to their daily routine. There is open visiting at the home, with relatives and friends able to visit at any time with the agreement of the residents. Relatives and friends spoke positively of the care and support provided at Manor Hall, they felt that they were listened to and that their opinions were an important part of the care provided. Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 Page 12 A choice is offered at all meals and snacks and drinks are available throughout the day. Residents said the food is good, they are able to choose their own meals and they can have something else if they change their minds. The cook caters for special diets and staff assist residents if required. Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 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 standard(s) EVIDENCE: These standards were not assessed. Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. The standard of the environment within this home is good providing residents with an attractive and homely place to live. All parts of the home are safe and accessible with satisfactory infection control systems in place to protect residents and staff. EVIDENCE: Manor Hall provides comfortable and homely individual and communal space for residents. There is a large lounge on the ground floor, with a dining area, that is also used for group activities. The home is well maintained and there is a programme of ongoing improvement. Updating the en suite facilities that are separated from bedrooms with a curtain is ongoing and there are long term plans to improve the kitchen and laundry areas. There is a patio area at the front of the building, accessed from the lounge, and one to the rear of the building, residents were using these during the inspection. Hoists and additional aids, including walking frames, assisted baths and toilets are provided to ensure that residents have access to all parts of the home and are able to use all the facilities. Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 Page 15 The bedrooms are furnished with adaptable beds, chairs and tables, radiators are guarded and there is natural ventilation in all the rooms. Residents are able to bring personal possessions to the home if they wish and many have personalised their rooms with pictures, ornaments and small pieces of furniture. Residents said they were comfortable in their rooms, some were listening to talking books, others were reading or watching the TV. On the top floor of the building is a flat with a separate lounge, kitchen, two bedrooms, a bathroom and a separate toilet. A married couple currently live in this flat and require personal support from the staff. The flat is bright and spacious and they have decorated it with their own possessions. The home was clean at the time of the inspection and there are systems in place to prevent the spread of infection. Staff demonstrated a clear understanding of the use of gloves and aprons as part of this process. Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29. Staff morale is high resulting in an enthusiastic workforce that work positively with residents to improve their whole quality of life. There are sufficient trained and competent staff on duty at all times to meet the assessed needs of residents. Robust recruitment procedures are in place to ensure the protection of service users. EVIDENCE: There is a dedicated team of staff working at the home, they have a range of skills and there are sufficient numbers to meet the needs of residents. The manager explained that all new members of staff receive TOPSS (Skills for Care) induction and foundation training, this was supported by the member of staff who started working at Manor Hall in the last two months. Care staff are also encouraged to work towards NVQ Level 2 and 3, there are currently just under 50 with NVQ Level 2, this includes student nurses and a further five are about to start working towards this. The homes recruitment policies are followed and appropriate checks are completed prior to an offer of employment. The manager discussed that POVA/CRB checks are completed at head office and it takes some time for them to be transferred to the homes and was advised that this practice is not acceptable and all relevant information will be kept in the home. Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 38. The manager is supported well by staff in providing clear leadership throughout the home with staff demonstrating an awareness of their roles. The health and safety of residents is put at risk with the use of door wedges to prop residents’ doors open. EVIDENCE: The management approach is open and encourages residents, relatives and staff to be involved in decisions taken about the services provided in the home. Residents, relatives and visitors who expressed an opinion said that they were consulted about all aspect of the care and support provided and were able to make choices with the staff encouragement. Mandatory training is provided for staff and includes manual handling and fire training. The manager discussed the previous requirement that advice should be sought from the fire service with regard to keeping fire doors open safely. She stated that risk assessments will be completed for all residents who request that the Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 Page 18 doors to their rooms are open during the day and a safe system of providing this will be in introduced. Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 x x x x x 3 Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 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 OP 38 Regulation 13 (4)(c) Requirement Advice to be sought from the Fire Service with regard to keeping service users doors open safely. Timescale for action 01.09.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Manor Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Hall H59-H10 S14017 Manor Hall V227346 140705 stage 4.doc Version 1.30 Page 22 - 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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