Inspection on 06/09/05 for Manor House

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Manor House 09/01/08

Manor House 01/02/07

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 Unannounced 6th September 2005 @ 09:40 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 I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 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) Category(ies) of registration, with number of places Care First Care Homes Limited, BUPA Care Homes To be confirmed Care home with nursing 43 OP(42) PD(E)(42) PD(1) Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) The number of nursing care places may not at any one time exceed 27 2) One named male with physical disability for the duration of their residency 3) The number of places for OP and PD(E) may not exceed 42 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 30/06/05 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 register the manager has been received for the Commission to consider. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second statutory inspection of Manor House for 2005/6. The inspection was carried out by two inspectors between 9:40 and 12:30 and took 3 hours to complete. At the time of the inspection there were 39 residents at the home and 9 of these were spoken to, although not all of the residents were able to express their views. Staff, including the manager, were spoken to also; a tour of the premises was made and documentation, including information provided by the manager before the inspection, was seen to complete the inspection process. Staff reported that, following meetings held by the manager, staff have been made aware of their responsibilities according to their roles. As a result of this increased awareness, staff considered that residents’ specific nursing needs are being met in a responsive and timely manner. Staff considered also, since the appointment of the manager, in May 2005, that the values of choice and dignity underpin the care that is provided to the residents. Staff made positive comments about the new manager, including the increased availability of moving and handling equipment and that staff felt well supported by him. What the service does well: The home does well in a number of areas: • Residents feel safe and happy living at the home. Comments made by residents included, “I like living here. I like the people”, and “Staff are very kind”. The front garden is well-maintained and colourful with seasonal flowers and vegetables. The home has a friendly atmosphere. There is an ongoing refurbishment programme to ensure residents live in a safe, comfortable and homely environment. • • • Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 6 • There is a commitment in improving the quality of acre and respecting residents’ choice and dignity. What has improved since the last inspection? Following the inspection in June there were 11 areas that the home could have improved upon. The home is to be commended on the improvements made in all the 11 areas identified. These are: • Care plans must contain assessments of residents that are accurate and up to date. Two requirements had been made about this and satisfactory action has been taken to meet these. Recorded evidence to prove that residents, or their representatives, have been consulted about drawing up their care plans should be considered. A recommendation was made about this and this has been considered. The original medication prescription must be seen before any medication is administered. A requirement was made about this and this has been met. The controlled drug register should contain full details of the dispensing pharmacist. A recommendation was made about this and this has been considered. The sort of item used for residents’ clothes to be protected when eating and drinking should be considered. A recommendation was made about this and this recommendation has also been considered. Residents’ dignity must be respected at all times. A requirement was made about this and this has been met. Residents must be consulted, where possible, about how, and when, they wish to have their care provided. A requirement was made about this and action has been taken to meet this requirement. The home must be maintained in a good state of repair. A requirement has been made about this. Details of this requirement regarding South Wing have been met. The home must reduce the risk of the spread of infection. A requirement has been made about this and this has been met. A fire drill instruction for staff has been carried out and as a result of this action the requirement has been met. I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 7 • • • • • • • • • Manor House What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these standards were assessed on this occasion. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 & 10 Residents’ health needs are met and their dignity is respected. EVIDENCE: Four residents’ care files were seen and the standard of the recording of these had improved. There was clear guidance for staff in how to meet the needs of the residents. In addition satisfactory action had been taken to ensure the assessments of the residents needs were accurate. As a result of these findings the two requirements have been met. The manager stated that arrangements have been made for the training of staff in developing and implementing care plans. A recommendation was made to evidence that residents, or their representatives, had been actively involved in drawing up the care plans. Four care plans were seen and, on the whole, evidence suggests that this recommendation has been considered. The manager stated that he has invited relatives to be actively involved with their relatives’ care plans and this is ongoing. As a result of these findings the recommendation about this has been considered made about this. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 11 One residents’ file was examined and evidence suggests that satisfactory action had been taken to ensure that appropriate care and treatment had been provided to aid the healing of a pressure sore that the resident had acquired prior to living at Manor House. Staff indicated that due to the redefining of roles and responsibilities with staff, residents’ specific nursing needs were being met in a responsive and timely manner. A requirement was made for the home to have sight of the original prescription. A visit to the treatment room was made and there was a number of original prescriptions available. As a result of this finding, this requirement has been met. Examination of the controlled drug register was carried out and included were records of the name and address of the dispensing pharmacist. A recommendation was made about this and this has been considered. Residents spoken to said that staff were kind and that they treated the residents well. Staff indicated that, since the appointment of the new manager, that residents’ dignity is valued and respected. During the last inspection it was noted that some residents were seen to be wearing disposable, and clinical in appearance, “bibs” to protect their clothing. During the tour of the premises, and discussion with the manager, more suitable tabards have replaced the disposable “bibs”. A recommendation was made about this and this has been considered. At the last inspection 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 considered as a recognisable act associated with a parent feeding a child. Although the meal time was not observed on this occasion the manager reported that action has been taken to eliminate this poor care practice. As a result of this full response it is considered that this requirement has been met. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14 &15 Residents’ choice is starting to be considered. EVIDENCE: Staff and 6 of the 9 residents able to do so, indicated that choice was sometimes offered to residents about how, and when, they wanted their care to be provided. The 4 care plans that were examined contained some evidence that choice was being offered to residents as part of consultation in drawing up the care plan. As a result of these findings it is considered that there has been action taken to improve the culture of care to include active consultation with the residents on a regular basis. It is considered, however, that this practice needs to continue to be developed to become consistent as the culture of care changes. A recommendation has been made about this. Although meal times were not observed on this occasion it was noted that dining areas were well presented with tablecloths, table decorations and napkins. Residents spoken to approved of the food and menus seen on display in the home, and copies provided by the manager in the pre-inspection questionnaire, indicated residents are given a choice, and variety of food. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these standards were assessed on this occasion. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 Systems are in place to ensure residents live in a safe, comfortable and clean home. EVIDENCE: Gardens to the front the house were well-maintained and colourful with seasonal flowers and vegetables. At the time of the inspection a resident was seated in the quiet, and shade, of the garden. During the tour of the premises it was noted, on East Wing, a large fissure had developed in one of the bedrooms. Examination of the corresponding external wall presented also with a large fissure. Two other fissures were noted on both internal corridor walls of East Wing, in fairly close proximity to the aforementioned fissures. The manager stated that arrangements have been made to address these structural defects. A request has been made for the manager to inform the Commission, in writing, of progress in this matter. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 15 Carpets on East Wing were noted to be clean, but showing signs of discolouration. The manager stated that funding has been agreed for replacement carpets and arrangements are in place for these carpets to be fitted. Other areas of the home presented with a good standard of décor and furnishings. At the last inspection it was noted the entrance to the corridor of South Wing was damaged in a number of areas around the doorframe, wall and the skirting board was coming away from the wall. During this inspection it was noted that repairs had been carried out to these damaged areas. In addition a radiator cover, further down the corridor of South Wing, had been damaged and this had been repaired. A requirement was made about these issues and this requirement has been met. The company has until July 2007 to ensure South Wing is suitable and fit for its intended purpose. The manager reported that action is being taken to address this issue. On the day of the inspection the home was clean and free of offensive odours. The manager reported action had been taken, including improving induction training of new staff, about the prevention of infection. This is a requirement that has been met. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Systems are in place to improve staff responsiveness in meeting residents’ needs. EVIDENCE: On the day of the inspection there was sufficient number of staff, including qualified staff, to meet the needs of the residents. The manager and staff reported that there is a review of how care is being provided. This review is part of the improvement in valuing residents’ choice of how, and when, they receive their care. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Residents are kept safe. EVIDENCE: Residents spoken to said that they felt safe living at the home. Information provided by the manager in the pre-inspection questionnaire notes that 5 care staff have attended training in first aid. This number complements the high percentage of qualified nurses (12) working at the home. During the last inspection records indicated that the home had not followed BUPA’s policy for fire drills to be carried out every 6 months. A requirement was made about this following this finding. At this inspection documentation was examined and records indicated that a fire drill practice was carried out on 15th July 2005. As a result of this action taken this requirement has been met. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 18 Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x 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 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x 3 Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 20 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 Regulation Requirement NONE Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP 14 Good Practice Recommendations The Registered Person should consider ways to continue to consistently include residents choice about how, and when, they wish to have their care provided. Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI Manor House I53 I03 S24320 MANOR HOUSE V247374 060905 STAGE 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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