Inspection on 30/10/06 for Manor Hall

This inspection was carried out on 30th October 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 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 Hall 12/04/10

Manor Hall 30/12/09

Manor Hall 03/03/08

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 Key Unannounced Inspection 30th October 2006 10:00 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 Hall DS0000014017.V315502.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.V315502.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 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability (38) of places Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of thirty-five (35) service users in receipt of nursing care and three (3) in receipt of personal care. Service users must be older people aged sixty-five (65) years or over on admission. Service users with physical disabilities under sixty-five (65) years may be admitted. 13th December 2005 Date of last inspection Brief Description of the Service: Manor Hall is registered to provide nursing care for up to thirty-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 separating 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. Fees for rooms at the home range from £550 to £680. Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over 9 hours on the 30th and 31st October. A pre-inspection questionnaire and residents survey forms were sent to the home prior to the inspection. The pre-inspection questionnaire was returned to the Commission. The inspection included a tour of the home, an examination of care plans, staff files, training records, accident records, menus and activity records. There were 34 residents at the home during the inspection. thirty-two requiring nursing care and two requiring residential care. 24 residents and a visitor were spoken with, those who expressed an opinion were very positive about the support they receive at the home. The manager, the registered nurses, care staff and cook were happy to discuss the care they provide for residents. The reader should be aware that the Care Standards Act 2000 and the Care Homes Regulations 2001 uses the terms service user to describe those living in care home settings, for the purpose of this report those living at care homes will be referred to as residents. What the service does well: Residents at Manor Hall are encouraged to regard it as their home and to make choices about how they spend their time. Residents were in the lounge or in their own rooms. Residents who expressed an opinion were very positive about the support they receive, they felt their needs were met ‘staff are very good and look after me’, and were able to decide with staff what care is most appropriate for them. Visitors were equally positive. The staff explained that Manor Hall ‘is the residents’ home’, they felt that they are able to provide appropriate care and are well supported by the manager. The atmosphere in the home was relaxed and comfortable, with communication between staff, residents and visitors open and friendly. Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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.V315502.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.V315502.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An appropriate pre-admission assessment is used prior to the offer of a room to ensure the home can meet prospective residents needs. EVIDENCE: Pre-admission assessments are completed for all prospective residents to ensure that the home can meet their needs. Some residents explained that they chose to come to this home, they had heard about Manor Hall from friends and relatives and were pleased that a room was available. Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 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. 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 is clear and consistent and provides staff with the information they need to satisfactorily meet residents’ needs. The systems for the administration of medicines are good with clear and comprehensive arrangements in place to ensure residents medication needs are met. 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 Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 Page 10 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. There is clear evidence that appropriate treatment is provided for residents who were admitted with pressure area damage, pressure relieving mattresses and cushions are provided, and daily records are kept to demonstrate improvements. 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 and are referred to 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. A residents is responsible for administering her inhalers, staff confirmed that this has been assessed as appropriate. This information should be included in the care plan and reviewed on a regular basis as part of the care package provided. Risk assessments, which have been completed to protect some nurses working in the home, should be extended to include the administration of medicines, as they have difficulty moving one of the medicine trolleys into the lift. This should include appropriate practices regarding administering medicines safely to residents. 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 ‘staff are good, look after me very well’, and their privacy is protected when they need help with personal care. Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 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. 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. 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: Some 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 and there are regular dog visits organised through P.A.T. Residents spoke positively about these and the monthly visits from the local nondenominational church group. A resident said that ‘I have everything I need, my books, the TV and my newspapers’. Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 Page 12 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. Friends spoke positively of the care and support provided at Manor Hall, although one did think that additional activities could be provided and this was passed on to the manager. 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. The chef has updated his skills regarding the provision of meals for residents with particular dietary requirements, and has produced a menu that caters for them and ensures that they have the same choices as other residents. Manor Hall DS0000014017.V315502.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. 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. The home has a satisfactory complaints system with some evidence that residents feel their views are listened to and acted upon. Staff have good knowledge and understanding of Adult Protection issues which protects residents from abuse. EVIDENCE: There have been no complaints regarding the services provided at Manor Hall since the last inspection, the manager confirmed appropriate policies and procedures are in place. Residents who expressed an opinion stated that they are able to make choices about all aspects of their day-to-day life, and if they have any worries or want to discuss something they care just talk to the staff. 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.V315502.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. 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. 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. Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 Page 15 Building work is currently taking place adding an extension to the rear of the home, and the drive through separating the building on the ground floor is being removed to make way for a main entrance with a reception area. Residents are aware what improvements are being made and those who expressed an opinion said they had not been disturbed by any noise. When the work has been completed there will an additional seven rooms at the rear, which will overlook a patio area, an additional lounge and parking spaces behind the building. 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. 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. 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 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.V315502.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. 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. 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. The arrangements for the induction of staff are satisfactory, enabling staff to provide appropriate levels of support and care for residents. EVIDENCE: There is a dedicated team of staff working at the home, they have a range of skills and the manager confirmed that there are sufficient numbers to meet the needs of residents. Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 Page 17 Staff who were spoken with said that they were able to provided the care and support residents need, ‘it is their home’ and we work with them to ensure ‘they live as independently as possible’ and make choices about what they do. The manager explained that all new members of staff receive induction training in line with Skills for Care, and staff are also encouraged to work towards NVQ Level 2 and 3. There are currently under 50 with NVQ Level 2 or equivalent, and 7 are towards this at the moment. 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 two of the care staff are working in the home, under supervision until the CRB check has been completed. Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 Page 18 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 the home is open and inclusive. Staff, residents and relatives are encouraged to be involved in any decisions about changes to the support and care provided. 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. Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 Page 19 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 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, about the care and support they receive. Mandatory training is provided for staff and includes manual handling, fire training, infection control, food hygiene and risk assessments. It was noted during the inspection that communication between staff, residents and visitors was open and friendly, the atmosphere was relaxed and residents were comfortable. The home is one of six care homes owned by the same company, with policies, procedures and quality assurance developed at head office and provided for each home. The manager advised that feedback from residents and their representatives is sought on a regular basis, with decisions about the services provided based on this information and the changing needs of residents. The home does not take responsibility for the finances of residents, although some petty cash is kept to pay for some additional costs, including hairdressing and chiropody. Receipts are provided for all payments and this is then added to the monthly invoice produced at head office. Previous requirements have been made concerning the use of propping resident’s doors open with wedges. This practice continues in the home, and a number of wedges were found in resident’s rooms. The manager advised that some residents feel they need to have the doors open. At the beginning of the inspection staff closed residents doors that were propped open and one resident clearly became distressed. This was discussed with the provider during the inspection and he stated that they would fit appropriate systems to enable some residents to keep their doors open safely. Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 Page 20 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 3 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Manor Hall DS0000014017.V315502.R01.S.doc Version 5.2 Page 21 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 OP38 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 01/03/07 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.V315502.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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.V315502.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. 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