Inspection on 03/03/08 for Manor Hall

This inspection was carried out on 3rd March 2008.

CSCI found this care home to be providing an Good service.

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 30/10/06

Manor Hall 13/12/05

Manor Hall 14/07/05

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 Unannounced Inspection 10:30 3 and 4 March 2008 rd th 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 Hall DS0000014017.V357715.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 Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Hall Address Borough Lane Eastbourne East Sussex BN20 8BB 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) 01323-722665 01323 647804 South Coast Nursing Homes Limited Ms Louise Murtagh Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44), Physical disability (44) of places Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to the following gender: Either Whose primary care needs on admission to the home are within the following categories: Physical disability - (PD) 2. Old age, not falling within any category - (OP) The maximum number of service users to be accommodated is 44. Date of last inspection 30th October 2006 Brief Description of the Service: Manor Hall is registered to provide nursing care for up to forty-four residents, and is situated in a residential area of Eastbourne, close to local amenities and public transport with an attractive park nearby. A considerable amount of work has been done to convert two buildings into this large care home, while still retaining many of its original features. A stair lift and two shaft lifts enable residents to access all parts of the home. There are two lounges one in each side of the building. The larger lounge has a dining area and is also used for activities. To the front of the home is a small patio area accessible through the main lounge, and there is an enclosed patio area between the main building and the rear extension. There is some parking at the rear of the building, which is accessible at the side of the home. Fees for rooms at the home range from £650 to £790. Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection was carried out on the 3rd and 4th March and took place over eight hours. The inspection included a tour of the home, a review of pre-admission assessments, care plans, staff records and training, medication records, activities, and menus. There were 42 residents at the home during the inspection. Twenty of the residents were spoken with and two visitors to the home were happy to discuss the support provided. The manager, registered nurses and the staff on duty discussed the care and support they provide at the home. The Annual Quality Assurance Assessment (AQAA) was completed by the manager, within the required timescale, and identified areas where improvements are planned for the benefit of residents. The reader should aware that the Care Standards Act 2000 and the Care Homes Regulations 2001 use the term ‘service user’ to describe those living in care home settings. However for the purposes of this report those living at Manor Hall will be referred to as ‘residents’. What the service does well: What has improved since the last inspection? Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 6 The one requirement of the last inspection was addressed immediately after this inspection. The majority of residents’ rooms at Manor Hall now have safe systems which enable residents to have their door open if they wish. An activity programme is being developed, with the co-ordinator arranging group activities on a Monday afternoon, and time with individual residents on a Thursday afternoon. The breakfast timetable has been extended to take into account the different times that residents may wish to get up. 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. The summary of this inspection report can be made available in other formats on request. Manor Hall DS0000014017.V357715.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 Hall DS0000014017.V357715.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the services offered at Manor Hall is available for all prospective residents. Pre admission assessments are completed to ensure the home can meet their needs and they are encouraged to visit the home. EVIDENCE: Information about the home and the support and services provided is available for prospective residents and their relatives. Pre-admission assessments are completed for all prospective residents to ensure that the home can meet their needs. Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 9 The residents spoken with at Manor Hall said the home had been chosen by their relatives, who had visited the home to see if it would be appropriate. They said their rooms were ‘very nice’ and found the home comfortable. Manor Hall DS0000014017.V357715.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system ensures that appropriate support and care is provided for residents, and they are protected by staff following the home’s procedures for medication. EVIDENCE: The pre-admission assessment is used as the basis of the individual care plans. The care plans include risk assessments for mobility, pressure area damage and the aids used to prevent this, nutritional assessments as well as a daily record of care provided, to ensure the particular needs of the residents are met. However some of the care plans are not up to date; the new form to evidence the involvement of residents and relatives in the decisions about the support provided and the night care plans were not completed in the care plans Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 11 viewed. The registered nurses spoken with said they did not have the time to complete these on a regular basis, but were able to demonstrate a clear understanding of the needs of the residents and the support they receive. The manager identified in the AQAA that additional time may be allocated for staff to complete the care plans and other essential records. Residents who expressed an opinion said that staff ‘look after me very well’ they are ‘very comfortable’ and ‘it is very nice here’. Residents are registered with GP’s of their choice, and since the last inspection they have arranged to have a GP service visit the home monthly. When required residents can see allied health professionals including physiotherapists, chiropodists and opticians. Policies and procedures are in place for ordering, storage, administration and disposal of medication, with medicine administration charts completed appropriately. The registered nurses said that there were no residents at the home who were responsible for their own medication at the time of the inspection. The manager advised that a risk assessment has been completed to protect staff when giving out medicines, if the registered nurses have difficulty moving one of the medicine trolleys. It was noted that the relationship between the staff, residents and visitors was friendly and relaxed, residents were treated with respect and their dignity was protected. Manor Hall DS0000014017.V357715.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about all aspects of their day to day lives, and the meals at the home are good, offering choices and meeting residents specific dietary needs. EVIDENCE: A programme of activities is being developed at the home by a senior care assistant. Monday afternoon is used for group activities and Thursday afternoon for time with individual residents. On the first day of the inspection a group of residents were in the lounge, some painting while others were playing skittles. All the residents spoken with were positive about the programme, with one saying ‘I really enjoyed myself’, and the atmosphere was very relaxed with the activity staff assisting residents as required. The expectation is that the programme will be extended so that activities can be offered at other times of the day, depending on the preferences of the residents. Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 13 Residents are encouraged to make choices about all aspects of their lives and a number prefer to spend their time in their own rooms. They know that activities are provided in the lounge but they prefer to spend their time reading or watching TV. Staff said this ‘is their home and they should make decisions about all aspects of the care we provide’. There is open visiting at the home, with relatives and friends able to visit at any time with the agreement of the residents. Visitors spoke positively of the care and support provided at Manor Hall. Links with the community are encouraged with weekly visits from local churches when required and a non-denominational group visit monthly. Regular visits are also made by dogs as part of the PAT group and theatre entertainment is arranged every few months. 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 what we want’ and they can have something else if they change their minds. Pureed meals are provided and staff assist residents if necessary. Residents choose where to have their meals, at lunchtime a number sit at the dining table, while others sits in armchairs in the lounges or their own rooms. Staff agreed during the inspection that residents sitting together should be given their meal at the same time, like they would at home, and the manager said staff will be expected to do this. Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to record and investigate complaints. Training in adult protection is provided for staff to protect residents from abuse. EVIDENCE: There has been one complaint regarding this service since the last inspection, the manager confirmed that this was investigated appropriately and action taken. Residents who expressed an opinion stated that they are able to make choices about all aspects of their day-to-day life, ‘they look after me very well’, and if they want anything they just ask. Training in adult protection and whistle blowing is provided for all staff at the home, this includes videos and questionnaires. Staff have a good understanding of the issues of adult protection and the friendly and open relationship between staff, residents and visitors was noted during the inspection. Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Manor Hall provides residents with a homely and comfortable place to live. All parts of the home are safe and accessible, and training in the control of infection is provided for staff to protect residents. EVIDENCE: The home has been extended and some parts have been refurbished since the last inspection. The penthouse floor is now registered for four rooms with a lounge, and there are an additional seven rooms to the rear of the building, the number of places registered has increased from 38 to 44. Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 16 There is an enclosed patio area between the new rooms at the rear and the main building, which staff advised is used by residents when they weather permits. The patio area accessible through the main lounge at the front of the building is also available for residents if they choose to use it. The drive through that previously separated the building on the ground floor has been replaced by a large main entrance, which extends to the rooms at the rear and now enables wheelchair access to either side of the building. There is a large lounge on the ground floor, with a dining area, that is also used for group activities. A smaller lounge has been provided near the entrance area and is preferred by some residents, although access from one side of the building to the other is through this small area. An additional communal area to replace the room previously used by staff was agreed during registration, but work has not yet started. Improvements have been made to the kitchen, the extractor fan and some of the appliances have been replaced, and other improvements are planned. In particular the replacement of the stands that are currently used to store the trays for residents meals. Hoists, including overhead hoists in a number of rooms, and additional aids including walking frames, assisted baths and toilets are provided. A chair lift and two shaft lifts ensure that residents have access to all parts of the home and are able to use all the facilities. 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 relaxing in bed while others were reading or watching the TV. The home is well maintained and there is a programme of ongoing improvement. 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 DS0000014017.V357715.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are in place, however some checks are not completed prior to unsupervised employment, which may put residents at risk. A training programme for staff is in place to enable staff to provide the support and care the residents need. EVIDENCE: The staffing levels at the home have been under review since the increase in number of registered places. Staff spoken with said there were times when they did not have as much time to spend with residents as they would like and these concerns were discussed during the recent team meeting. The manager advised that an additional health care assistant is being employed to address this. The manager and staff feel that this will enable staff to offer a satisfactory level of support to residents. Staff spoken with said that they provide the care and support that encourages residents to be independent. ‘It is their home’ and we work with them to ensure ‘they live as independently as possible’ and make choices about what they do. Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 18 The registered nurse responsible for training confirmed that all new staff are required to complete appropriate induction training and also to attend all the mandatory training as a requirement of their employment. Staff are also encouraged to work towards National Vocational Qualifications (NVQ’s), currently the home has less that 50 of staff with these or equivalent qualifications, however 7 members of staff have recently been accepted to work towards NVQ Level 2. The home’s recruitment policies are followed and staff advised that appropriate checks are completed prior to an offer of employment. Protection of Vulnerable Adult (POVA) and Criminal Register Bureau (CRB) checks are completed at head office and it was noted that two of the care staff working in the home are doing so with only a POVA first completed. This is acceptable when the staff members are being supervised at all times, however clearly this cannot be guaranteed for one of the staff, and in such instances residents may be at risk. The suggestion was that they may be at head office and have not yet been sent through, they were not available during the inspection, which took place over two days. Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 19 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management approach at Manor Hall is open and encourages residents, relatives and staff to be actively involved in decisions about the services provided at the home. The health and safety of residents is protected through an ongoing training programme for staff. EVIDENCE: Discussions about the services provided at the home take place on a daily basis with residents, relatives and staff. To develop this further the manager Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 20 plans to set up residents and relatives meetings to encourage them to participate in decisions about developing the support provided. The manager confirmed that feedback is sought from all groups and individuals who have any contact with the home, as part of the quality assurance system. A questionnaire was used last year to obtain feedback from residents. This has resulted in a more flexible breakfast period and the development of an activity programme. The comments from residents and relatives during the inspection were very positive, and there were no suggestions as to how they service could be improved from anyone, including staff. Training required by legislation, including moving and handling, fire training and infection control is provided for all staff to protect the health and safety of residents. However it was noted that staff were using an inappropriate lift when assisting a resident to stand up in the lounge, the manager advised that this would be addressed. It was noted in the inspection that some residents doors were being wedged open or held open with chairs. The manager has advised that following the inspection systems to hold residents doors open safely have been placed on doors that residents prefer to keep open, and they will be on all the doors as soon as possible. Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 21 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 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 Requirement Timescale for action 16/05/08 2. OP29 19 (d) Schedule 2 Care plans to be up to date and under regular review, with the involvement of residents and/or relatives, to protect residents. Appropriate checks to be 05/03/08 completed prior to unsupervised employment to protect residents. 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 Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection South East The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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. Extracts may not be used or reproduced without the express permission of CSCI Manor Hall DS0000014017.V357715.R01.S.doc Version 5.2 Page 24 - 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. 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