Inspection on 01/02/07 for Manor House

This inspection was carried out on 1st February 2007.

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 House 09/01/08

Manor House 06/09/05

Manor House 30/06/05

Manor House 19/10/04

Manor House 13/07/04

Manor House 19/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Manor House 80 Huntingdon Road Upwood Huntingdon Cambridgeshire PE17 1QQ Lead Inspector Elaine Boismier Key Unannounced Inspection 1st February 2007 9:25 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 House DS0000024320.V316595.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 House DS0000024320.V316595.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor House Address 80 Huntingdon Road Upwood Huntingdon Cambridgeshire PE17 1QQ 01487 814333 01487 710083 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) www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited Care Home 43 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (38), of places Physical disability (1), Physical disability over 65 years of age (38) Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The number of nursing care places may not exceed 27 at any one time One named male under 65 years of age with physical disability for the duration of their residency. The number of places for OP and PD(E) may not exceed 38 for the duration of conditions number 2 and 4 The number of places for DE(E) may not exceed 4 at any one time The total number of people accommodated in the home may not at any one time exceed 43 6th September 2005 Date of last inspection Brief Description of the Service: Manor House is an adapted 19th Century domestic dwelling located in the small village of Upwood, about 3 miles from Ramsey. The building, that has served as a vicarage and later a surgical unit for overseas military, is arranged on two levels with well-maintained gardens to the front of the home. Parking is available to the front of the home. Accommodation is on two floors, with a lift to the first floor. The home is registered to provide accommodation care, including nursing care, for a maximum number of 42 service users over 65 years of age. Applications for minor variations of registration have been approved for 4 places for people over 65 years of age with dementia and for one named person under 65 years of age with a physical disability. Current fees range from £351 to £605. Additional costs include those for chiropody, hairdressing and newspapers. A copy of the inspection report is available on request at the home or via the CSCI website. A vacancy has arisen for a registered manager. Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the key inspection of Manor House for 2006/7. The inspection was unannounced and was carried out between 9:25 and 14:35 and took just over 5 hours to complete. On the day of the inspection there were 37 residents living at the home and 4 of these were spoken to. A tour of the premises was made, staff and the Home Manager were spoken to and documentation was examined. Information provided to the Commission before this inspection has been examined and reference to this information can be found in this report. Forty-three residents’ surveys were sent out and 15 of these were returned. Comments contained in these surveys are also referred to in this report. Manor House currently provides an adequate standard of care in a wellmanaged service. What the service does well: What has improved since the last inspection? Following the last inspection of the home there was no requirements and one recommendation. This recommendation was that to continue to consistently include residents choice about how, and when, they wish to have their care provided. This recommendation has been considered. Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 6 What they could do better: There were some, but not all, records of what activities the residents engaged in. A recommendation has been made for this area of record keeping to be developed. Residents who are giving their own medication must have a risk assessment carried out and this assessment recorded. A requirement has been made about this. Medication must be stored in a safe manner. A requirement has been made about this. Medication records must be accurate. A requirement has been made about this. A recommendation has been made for a survey to be carried out to assess what activities residents would like to take part in. A recommendation has been made for a review of the methods and times of cooking of food. An outstanding requirement exists for the South Wing to be made safe and accessible for residents. Timescale for this requirement is July 2007. A recommendation has been made for an audit of the level of needs of residents and to compare this with the number and range of staff available. A recommendation has been made for the home to be managed by a registered person. Records for fire drills did not always include the names of those in attendance. A recommendation has been made about this. Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 7 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 House DS0000024320.V316595.R01.S.doc Version 5.2 Page 8 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 House DS0000024320.V316595.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. Prospective residents have access to a good standard of information to assist them in their decision where to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of 6 residents’ care notes indicated that an assessment of their health and social care needs had been carried out before the person entered the home. These assessments were made by staff of the home, hospital staff and staff employed by the local authorities. Manor House DS0000024320.V316595.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 & 10 Quality in this outcome area is adequate. Residents receive a good standard of health and personal care by respectful staff although medication storage and records for medication are to be improved upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six residents’ care records were examined and on the whole these were detailed. Discussion with staff indicated that both residents and relatives are included in the drawing up the care plans and also are involved in the reviews of the care plans. There were some, but not all, records of what activities the residents engaged in. A recommendation has been made for this area of record keeping to be developed. Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 11 93 of respondents of the residents’ survey considered that they always received the medical support that they needed; 17 of respondents of the residents’ survey considered that they usually received the medical support that they needed. Examination of 6 residents’ care records indicated that residents have access to GPs, district nurses and hospital specialists. The controlled drug register was examined and two controlled drugs were counted and the amount available reconciled with the recorded balance. Temperatures of the medication room and drug fridge are recorded daily and these recordings were satisfactory. Examination of medication administration records was also carried out and on a few occasions entries were confusing. According to staff these entries were to demonstrate that the resident had declined the medication although there was no definition of this entry. The same medication records had later entries for when the resident had accepted the medication, at a later time of the day. A requirement has been made for accurate record keeping. During the tour of the premises it was noted that a resident had medication, in a basket, by their side. The resident confirmed that this was the usual place for it to be kept, although the resident stated that they were not always in their room. A requirement has been made about this. Currently two residents are responsible for giving their own medication although there was no risk assessment carried out to ensure the residents were safe and able to do so. A requirement has been made about this. Residents spoken to said that the staff were good. Examination of the minutes of the residents’ meeting, held on 24th January 2007, included positive comments about staff including, “F could not speak highly enough of care staff”, and other positive comments about staff were, “Echoed by other residents.” Staff were observed to interact with residents in a polite and appropriate manner. Manor House DS0000024320.V316595.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 & 15 Quality in this outcome area is good. Residents generally live a good quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 60 of respondents of the residents’ survey considered that the home always provided activities that the resident could take part in; 27 of respondents of the residents’ survey considered that the home usually provided activities that the resident could take part in; 13 of respondents of the residents’ survey considered that the home sometimes provided activities that the resident could take part in. During the tour of the premises it was noted that photographs of events were on display. These photographs included visits to the home by entertainers, pat dogs and owls (that belong to the local raptor centre). Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 13 Discussion with residents indicated that some chose not to engage in the activities provided at the home, although had expressed another choice of activity, not currently available. A recommendation has been made for a survey to be carried out to establish what activities all residents would like to be involved in. Residents stated that they received guests and care records confirmed this. At the time of the inspection some residents were receiving their guests at the home, both in private and in the communal areas. A recommendation was made for residents’ choice to be consistently valued. Discussion with residents and obsevation of staff indicated that this recommendation has been considered. Residents are given choices of when to get up, when to go to bed, what to wear and choices in food and drink. 47 of respondents of the residents’ survey said that always liked the meals at the home; 43 of respondents of the residents’ survey said that usually liked the meals at the home; 5 of respondents of the residents’ survey said that sometimes liked the meals at the home; 5 of respondents of the residents’ survey said that they were given food by artificial methods rather than eating the meals. Comments in the residents surveys included “Great food” and” Very enjoyable”. Residents spoken to had a range of views about the standard of food from “Rubbish” to “Very good”. Staff, including the Home Manager, indicated that suggestions about the food, made by residents during their meeting of 24th January 2007, were being acted on. Discussion with staff indicated that the cooking of vegetables for the lunch (including leeks and carrots) had commenced almost 3 hours before serving the meal. A recommendation has been made for a review of the methods and times of cooking of food. Manor House DS0000024320.V316595.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 & 18 Quality in this outcome area is good. Residents are listened to and are safe from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided by the former Registered Manager prior to the inspection indicated that the home had 3 complaints of which 2 were substantiated and one complaint was substantiated in part. All complaints were responded to within 28 days. The Commission has received no complaints made against the home. 74 of respondents of the residents’ survey stated that they always knew how to make a complaint; 13 of respondents of the residents’ survey stated that they usually knew how to make a complaint; 13 of respondents of the residents’ survey stated that they sometimes knew how to make a complaint. One respondent provided information about how the home responded to a complaint in a satisfactory and listening manner. The majority of residents said Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 15 that they knew who to speak to if they were unhappy about something in the home. The record of complaints was satisfactory. Information provided by the former Manager before the inspection indicated that there has been no allegations of abuse. The Commission has received no reports of allegations of abuse against any resident since the last inspection. Staff confirmed that they had received training in the protection of adults against abuse. Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 16 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 & 26 Quality in this outcome area is adequate. Most areas of the home are suitable for residents. Residents live in a well-maintained and clean place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made for part of the home to be made fit for purpose by July 2007. This requirement was related to that of the South Wing. Examination of the corridor of this area was again carried out. Findings indicated that this area of the home is currently not fit for purpose due to the narrow width of the corridor. The space provided is also compromised by Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 17 angles of walls when entering the corridor and corridor space taken up by wall heaters. Discussion with the Home Manager indicated that should a resident require assistance with the use of a hoist or the use of an ambulance trolley then the space afforded by South Wing would not be sufficient. As such this poses a risk to the health and safety of residents with changing health needs, including suddenly occurring ill health. This requirement and timescale remains. A tour of the external premises was made and it was noted that an external wall of the Primrose Suite has a large crack in the structure. According to the Home Manager this is currently being assessed. Information provided by the former Manager before the inspection notes that some areas of the home have had carpets replaced in some rooms and in the main corridors. At the time of the inspection the Home Manager reported that some areas of the home have been redecorated and there is a system in place for redecoration of residents’ bedrooms and changes to the reception area. 80 of respondents of the residents’ survey considered that the home was always fresh and clean; 20 of respondents of the residents’ survey considered that the home was usually fresh and clean. One respondent stated that the domestic staff “Work very hard”. On the day of the inspection staff were shampooing carpets and the home was clean and smelt fresh. Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 18 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 & 30 Quality in this outcome area is good. Residents receive care from staff who are generally well recruited and well trained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection there was sufficient number of staff on duty to meet the current needs of the residents. Residents said that they did not usually need to wait long for a member of staff to assist them. Staff had mixed views about staffing numbers and considered that the level of needs of residents had slowly increased over a period of 2 years. Although there was insufficient evidence to suggest that residents were not receiving care and receiving such care in a timely manner, a recommendation has been made for an audit to be carried out. The home has more that 50 care staff with NVQ level 2 or equivalent. Examination of 3 staff files was carried out and the majority of required information had been obtained before the staff worked at the home. The exception to this was an unexplained gap in employment history of over two Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 19 years for one of 3 staff members. This gap was of a past employment, rather than the most recent employment. The Commission has taken a reasonable view not to make this a requirement on this occasion as it is expected that the home will obtain this missing information, without regulation requiring this action. Information provided by the former Manager before the inspection notes that training has been attended by staff to include wound care and dressings, challenging behaviour, infection control, protection of vulnerable adults against abuse and care of people with difficulties with continence. This attendance in training was also confirmed by staff. Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. Residents live in a home that is well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home Manager was appointed to his current position in January 2007. He has previous managerial experience both in the community and care homes. Staff were positive about their new manager. One comment included, “He has come here to put the icing on the cake.” The Commission has yet to receive an application to register the Home Manager. Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 21 A recommendation has been made for the home to be managed by a registered person. The Commission receives copies of reports of monthly visits to the home. These reports include audits of the premises, audits of complaints and views of both residents and staff about the home. According to the Home Manger the company has carried out a quality assurance survey and results of this are awaited. Currently nine residents have chosen the home to keep safe their personal monies. Balances of these monies were checked and monies available were counted. The amount available reconciled with the balances. Information provided by the former Manager before the inspection notes that training has been attended by staff to include first aid and moving and handling. Three staff files that were examined and discussion with staff confirmed this to be the case. Records for temperatures for hot water checks, PAT tests, emergency lighting checks and fire alarm checks were satisfactory. Records for fire drills were also seen although these did not always include the names of those in attendance. A recommendation has been made about this. Examination of the inspection report of the passenger lift was carried out. This report indicated that the lift is “in a poor condition”. According to the Home Manager action is being taken to address this issue. Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 22 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 2 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 3 2 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 2 x 3 x 3 x x 3 Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 15(1) Requirement Timescale for action 22/02/07 2. 3. 4. OP9 OP9 OP19 13(2) 13(2) 23(1) The Registered Person must ensure that service users are risk assessed with regards to administering their own medication. The Registered Person must 02/02/07 ensure that medication is stored in a safe manner. The Registered Person must 02/02/07 ensure that records for medication are accurate. The Registered Person must 31/07/07 ensure that all areas of the home are fit for purpose. 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. 2. Refer to Standard OP7 OP12 Good Practice Recommendations The service user’s plan should continue to be developed to include details of the service user’s social care needs. A survey should be carried out to elicit service users’ choice in activities. DS0000024320.V316595.R01.S.doc Version 5.2 Page 24 Manor House 3. 4. OP15 OP27 5. 6. OP31 OP38 A review of the methods and times of cooking of food should be carried out. An audit of the level of needs of service users should be carried out to elicit if the numbers and skills of staff are sufficient and approriate to meet the service users assessed level of needs. The home should be managed by a registered person. The record of fire drills should contain the full names of those in attendance. Manor House DS0000024320.V316595.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 House DS0000024320.V316595.R01.S.doc Version 5.2 Page 26 - 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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