Inspection on 30/06/05 for Manor House

This inspection was carried out on 30th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 01/02/07

Manor House 06/09/05

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 Unannounced 30 June 2005 @ 10:10 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 House Version 1.10 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care First Care Homes Limited, BUPA Care Homes To be confirmed Care home with nursing 43 Category(ies) of OP(41) PD(E)(41) PD(2) registration, with number of places Manor House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1) The number of nursing care places may not at any one time exceed 27 2) Two named males with physical disability for the duration of their residency 3) The number of places for OP and PD(E) may not exceed 42 or 41 respectively for the duration of condition number 2 4) The total number of people accommodated in the home may not at any one time exceed 43 Date of last inspection 19/10/04 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 and one service user under 65 years of age as a minor variation of registration. An application to admit a service user under 65 years of age, to live at the home for episodes of respite care, has been approved by the Commission. Due to a vacancy arising the company has appointed a new manager. An application to register the new manager, with the Commission, has yet to be made. Manor House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This summary includes also additional visits made to the home since the unannounced inspection in October 2004. Following the unannounced inspection of the home of 19th October, on 24th October 2004 the Commission for Social Care Inspection issued an enforcement notice against the home about poor standards of care with regards to the protection of residents against the development of pressure sores and the insufficient action taken in response to findings of recorded “unintentional weight loss” of residents. On 17th November 2004 an unannounced additional inspection was made to monitor the health and welfare of service users, during the agreed extension of time for Manor House to comply with the requirements detailed within this enforcement notice. Findings indicated that clear guidance was recorded as to how care staff were to meet the assessed needs of the service user regarding care and prevention of pressure sore development and the action that had been taken in response to recorded weight loss. It was considered, as part of good practice, that a review date should be specified on the care record. However, as the number of care plans seen was small, a full judgement was not made at this time. Further findings, during the tour of the premises included an observation that staff were assisting service users, accommodated on South Wing, with moving and handling. Mobility aids used by staff included a hoist and wheelchair. It was observed that the safe manoeuvring of service users, to and from their rooms on South Wing, to be compromised due to the structure of the build. Staff confirmed that they encountered some difficulties when assisting service users with mobility needs, on South Wing. As a result of this the home was required to carry out a risk assessment within the context of the structure of the premises, of residents, accommodated on South Wing, who required assistance with moving and handling. The home responded to this requirement in writing, detailing what action had been taken. Staff confirmed, at this inspection, that residents currently living on South Wing were independent with their walking. A further unannounced inspection of the home was carried out on 8th December 2004. The purpose of this inspection was to fully assess the home’s compliance with the requirements made within the enforcement notice that was issued in October 2004. The findings of this additional inspection confirmed that compliance had been achieved. Manor House Version 1.10 Page 6 This is the first inspection that was unannounced, of Manor House, for 2005/6. The inspection was carried out by two inspectors between 10:10 and 16:00 and took almost 6 hours to complete. On the day of the inspection there were 36 residents and 7 of these were spoken to, although not all were able to tell the inspectors their views of the home, due to their conditions. During the course of the inspection 2 visitors were spoken to and 12 staff, in groups and individually were also spoken to, including ancillary staff, care staff, qualified nurses and the Acting Clinical Manager. Due to the home manager not being available, due to leave commitments, a home manager from a local BUPA care home was present at most of the inspection. A tour of the premises was made and documentation was seen to complete the inspection process. Favourable and positive comments from staff were received about the new manager, including, “ Fantastic working with Henry. He has similar ideas (as us) about running the home”, and, “ He is very approachable. Even if his door is closed, you can just knock on it if you want to see him”. Improved changes to documentation, including staff recruitment files and staff supervision records, have been implemented since the manager has been appointed. What the service does well: What has improved since the last inspection? The home has improved in 9 noticeable areas: • The home has met 5 requirements made and has considered the two relevant recommendations made following the unannounced inspection of October 2004 and the requirement made following the additional inspection of November 2004. Version 1.10 Page 7 Manor House • • A new patio area, with garden furniture and a water feature, has been built for residents to access. Arrangements have been made to make sure residents needing help with meals do not have to wait for their food. What they could do better: The home could improve in 11 noticeable areas: • • Care plans must contain assessments of residents that are accurate and up to date. Two requirements have been made about this. Recorded evidence to prove that residents, or their representatives, have been consulted about drawing up their care plans should be considered. A recommendation has been made about this. The original medication prescription must be seen before any medication is administered. A requirement has been made about this. The controlled drug register should contain full details of the dispensing pharmacist. A recommendation has been made about this. The sort of item used for residents’ clothes to be protected when eating and drinking should be considered. A recommendation has been made about this. Residents’ dignity must be respected at all times. A requirement has been made about this. Residents must be consulted, where possible, about how, and when, they wish to have their care provided. A requirement has been made about this. The home must be maintained in a good state of repair. A requirement has been made about this. The home must reduce the risk of the spread of infection. A requirement has been made about this. The home must arrange for fire drill instruction for staff. A requirement has been made about this. • • • • • • • • Manor House Version 1.10 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manor House Version 1.10 Page 9 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 House Version 1.10 Page 10 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) 3 Prospective residents are assessed to make sure their needs can be met. EVIDENCE: A sample of 4 residents care files were seen, and discussion with the Acting Clinical Manager, confirmed qualified and trained individuals assess prospective residents to ensure the home is suitable and able to meet the assessed needs of the person. Manor House Version 1.10 Page 11 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) 7,8,9 &10 Methods of recording could pose a risk to residents’ health and safety, although health needs of residents are met. Residents’ privacy is respected at all times although the value of dignity is sometimes compromised. EVIDENCE: Four residents’ care files were seen and the standard of the recording of these was variable. The two care plans seen for residents with personal care needs only were detailed with assessments, including risk assessments and there was clear guidance for staff in how to meet the needs of the residents. However the two care files for residents’ with nursing needs provided assessments for risks and care needs, although the assessments did not always reflect accurately the need of the resident. For example a care plan stated that the resident needed assistance with feeding. During lunchtime it was noted that the same resident was independent in eating and drinking. Daily progress notes indicated that residents’ health needs had changed although there was no care plan for staff in how to meet the changed needs of the resident. Two requirements have been made following these findings. Manor House Version 1.10 Page 12 Relatives visiting the home said that they had been consulted about their mother’s care plan and staff were able to describe how care plans were drawn up in consultation with the resident or their representative. The requirement made following the inspection in October 2004 has been met. However there was no record to evidence this activity. A recommendation has been made about this. The home employs a large number of qualified nurses. In addition the residents’ care notes seen contained details of visits made to residents by GP, physiotherapy and district nurses visits. Records of residents’ weights were recorded and what action had been taken in response to unusual findings. This is a requirement that has been met. The Acting Clinical Manager said that no resident had a pressure sore. This is a requirement that has also been met. An assessment of the medication systems in the home included the receipt of medication; the storage and recording of controlled medication and the standard of recording of the medication administration sheets. The Acting Clinical Manager stated that the home does not have sight of the original prescription. A requirement has been made about this. Two amounts of controlled medication were checked and these were correct although there was no record of the name and address of the dispensing pharmacist. A recommendation has been made about this. The standard of recording of the medication administration sheets was satisfactory. Residents said that staff knocked on bedroom doors before they entered and it was noted that staff interacted with residents in an appropriate manner. However during lunchtime some residents were seen to be wearing disposable, and clinical in appearance, “bibs” to protect their clothing. A recommendation has been made about this. In addition it was noted also that a member of staff was blowing on spoons of hot food prior to giving the food to a resident. This was discussed with the visiting home manager and Acting Clinical Manager as a recognisable act associated with a parent feeding a child. (See also standard 26). A requirement has been made about this. Manor House Version 1.10 Page 13 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 & 15 Residents’ social needs are generally well met although the value of choice is sometimes compromised. EVIDENCE: Residents and relatives said that activities provided at the home are suitable, including outings, games, visiting entertainers and residents and their guests make visits to the well maintained garden areas, including the new patio. Relatives and residents confirmed that residents receive their guests at any time. It was noted at the time of the inspection that residents were receiving guests in the lounges and in private. Residents, able to make their views known, said that choices of when to get up and when to go to bed were respected although staff indicated that residents, unable to make their choices known, were assisted out of bed “to fit in” with the work arrangements of staff. A requirement has been made about this. Lunchtime was observed and it was noted staff were seated whilst assisting residents with their meal. Residents said that choice of menu was available at all times and that the food was good. Dining tables were arranged and decorated to give a homely feel. A member of staff said that since the new manager has been in post, seating arrangements of residents needing Manor House Version 1.10 Page 14 assistance have been changed and as a result of this, residents do not have to wait for their food. Manor House Version 1.10 Page 15 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) 16 & 18 Residents and relatives feel their complaints are listened to and the home is safe to live in. EVIDENCE: The record of complaints was seen and was satisfactory. Residents who have made their concerns, or complaints, known were satisfied with the home’s response to these. In June 2005 the home followed correct procedures, to ensure the safety of residents against abuse. Residents said that they felt the Manor House was a safe place to live in. Manor House Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 Residents enjoy a spacious and clean environment although an area of the home was not homely or well maintained. EVIDENCE: The home is surrounded by well-maintained and pleasant garden areas including a newly built patio area, furnished with garden furniture and decorated with a water feature. There are also a number of lounges and the décor of the home is generally good. During the tour of South Wing it was noted the entrance to the corridor was damaged in a number of areas around the doorframe, wall and the skirting board was coming away from the wall. A radiator cover, further down the corridor of South Wing, was also damaged. A requirement has been made about this. The company has until July 2007 to ensure South Wing is suitable and fit for its intended purpose. On the day of the inspection the home was clean and free of offensive odours. Staff training files indicated some staff have attended training in infection control. During lunchtime a member of staff was seen to blowing on hot food before giving it to the resident (See also standard 15). A requirement has been made about this. Manor House Version 1.10 Page 17 Manor House Version 1.10 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 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, 28,29 & 30 Residents receive care from trained and a high number of qualified staff. Systems for the recruitment and vetting procedures of staff have improved. EVIDENCE: Residents and relatives considered that staff numbers are sufficient and residents’ care needs are met. The Acting Manager said that recruitment of new staff to the home has been successful. At the time of the inspection there was sufficient number of staff to meet the needs of the residents. The home prides itself on having a large number of qualified nursing staff, and as such, has a minimum of 50 staff with NVQ level 2 or equivalent. Three staff files were seen. Information about staff, as required, was available and this is a requirement that has been met. The new home manager has introduced new documentation for the recruitment and vetting of staff to ensure protection of residents against the risk of abuse. Staff training files assessed indicated that staff have attended training in aspects of health and safety, to include infection control, moving and handling and fire safety. Staff reported that additional training in clinical issues has been discussed with the new manager. Manor House Version 1.10 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 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) 33,35, 36 & 38 The home is generally run in the best interests of residents although there is some risk of safety to residents and others at the home. EVIDENCE: The Commission receives monthly reports of visits to the home carried out by the a designated person for BUPA. The home’s administrator reported that audits of information about residents are carried out at least once a year. The home is appointee for one resident. An assessment of the record of the resident’s personal monies was carried out and information seen was satisfactory. Following the appointment of the home manager supervision arrangements of staff is improving. Three staff files were assessed and detailed records of Manor House Version 1.10 Page 20 regular supervision were seen. This is a recommendation that has been considered. Records for accidents, fire alarm and emergency lighting checks and checks for hot water temperatures were satisfactory. The record for the last fire drill indicated this to have been carried out on 3rd September 2004; BUPA’s policy is that a fire drill should be carried out every 6 months. A requirement has been made about this Manor House Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 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 Standard No 16 17 18 Score 3 x 3 x x 3 x 3 3 x 2 Manor House Version 1.10 Page 22 NO 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 7 Regulation 15 Requirement The Registered Person must ensure service users needs are assessed and care records give clear guidance for staff in how to meet these needs The Registered Person must make sure the service users plan is revised at any time when it is necessary to do so having regard to any change of circumstance The Registered Person must make sure sight of the original prescription is made by the home The Registered Person must make sure service users dignity is respected at all times The Registered Person must make sure, where possible, service users are consulted about their choice of how, and when, they wish to have their care provided The Registered Person must make sure the premises are kept in a good state of repair The Registered Person must make arrangements for the prevention of spread of infection The Registered Person must Version 1.10 Timescale for action 15/07/05 2. OP 7 14 (2)(b) 15/07/05 3. OP 9 13(2) 31/07/05 4. 5. OP 10 OP 14 12(4)(a) 12(2) 07/07/05 31/07/05 6. 7. 8. OP 19 OP 26 OP 38 23(2)(b) 13(3) 23(4)(e) 13/07/05 07/07/05 15/07/05 Page 23 Manor House make arrangements to ensure that, by means of fire drills and practices, staff are of evacuation procedures 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. 3. Refer to Standard OP 7 OP 9 OP 10 Good Practice Recommendations The Registererd Person should consider methods of recording to demonstrate that residents, or their relatives, have been consulted in drawing up the plan of care The controlled drug register should contain details of the name and full address of the dispensing pharmacy Consideration should be made for residents to wear protective clothing, whilst eating and drinking, that is less clinical looking Manor House Version 1.10 Page 24 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB1 5XE 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. 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