CARE HOMES FOR OLDER PEOPLE
Manor House Christian Rest Home Bacton Stowmarket Suffolk IP14 4LJ Lead Inspector
Anna Rogers Unannounced Inspection 28th November 2005 09:30 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 Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 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 Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Manor House Christian Rest Home Address Bacton Stowmarket Suffolk IP14 4LJ 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) 01449 781447 01449 781447 Manor House Christian Trust Mrs Miranda Jolly Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: Manor House Christian Rest Home is a large 16th Century building situated in the centre of the village of Bacton, close to local amenities. It is surrounded by approximately three acres of grounds which include an orchard to the rear of the property. There is a large farm to one side of the home and a GP surgery to the other side. The building is privately owned and leased by the Manor House Christian Trust for the purpose of providing residential accommodation for older people, within a Christian community. The Trust are somewhat restricted as to any adaptations they can make to the property as it is a listed building and formal negotiation is required before any permission will be given to make any changes. The Trust are responsible for the upkeep and maintenance of the property. The home offers accommodation and care for up to sixteen older people, the majority of whom are practicing Christians. However, local people who do not follow the Christian faith would not be precluded from living at the home. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over 4.5 hours on a weekday. During the inspection 3 members of staff including the Deputy Manager were spoken with. Six residents were spoken with individually. The communal areas of the home and bedroom 2 which required a new carpet were seen. A number of documents including a new residents care assessment, care plans, risk assessments and health care records including the administration charts for medication were inspected. The recruitment procedure was inspected for a new member of staff who joined the care team since the last inspection. What the service does well:
Residents spoken with confirmed their satisfaction with the care they receive. Residents said that their relatives are also made to feel welcome when they visit and one resident described the atmosphere as “like one big family”. The weather on the day of this inspection was very cold and frosty but the home was comfortably warm and residents said, “staff always ask if you are warm enough”. All residents seen were dressed appropriately for the climate and their clothing looked cared for. The majority of residents were sitting in the lounge after joining in with the regular Morning Prayer meeting, which is conducted by The Chairman of The Trust. Some of the residents were listening to the background music and chatting with others or watching the birds through the window while others were reading and one resident was knitting to make up blankets to send overseas. There was evidence that resident’s needs are assessed and these are identified on their care plans. The personal care element of the care plan is kept in the resident’s bedroom and staff confirmed they refer to this to make sure they are following the residents preferred routines. There was also good documentary evidence of risk assessments to support resident’s lifestyle. The home is committed to training and The Deputy Manager confirmed that three members of staff are hoping to undertake National Vocational Qualification (NVQ) level 2 training. There was also evidence that staff undertake core training for example, Manual Handling, Fire safety, First Aid and Health and Safety as well as more specialist subjects relating to the care of older people. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
The representative undertaking the Regulation 26 visits mentioned in their last report the need to develop activities following a requirement made following the last inspection. Discussion with residents confirmed that seasonal related entertainment has been arranged for December for example a local school is to visit to do a nativity play and sing carols and the Women’s Institute (WI) are also to visit to sing carols. However there is a need to develop activities both in and outside of the home. Staff supervision is currently undertaken approximately four times a year but to meet the standard this should be increased to six times a year. The Chair of The Trust was spoken with briefly during this inspection to discuss the outstanding requirement to provide evidence that the home has ongoing financial viability. The Chairman said he would “chase up” the outstanding financial statement and forward it to the Commission. This needs to be actioned. Please contact the provider for advice of actions taken in response to this
Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 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 Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 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 the following standard(s): 2 ,3 (Standard 6 does not apply to this service). Residents can expect to be provided with terms and conditions that set out the facilities and care they will receive. Residents can expect that their needs will be identified. EVIDENCE: Residents are provided with details of the terms and conditions of their stay at the home. One resident recently admitted said her relatives had been instrumental in finding her a place at Manor House. There was written evidence that an assessment had been completed. These included a discharge assessment from the hospital and also an assessment completed by the registered manager. It was clear from the assessment information and discussion with the resident that the placement is within the homes category of registration. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 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 the following standard(s): 9,11 Residents can expect that staff will ensure that medication is given at the prescribed times and an accurate record will be maintained. Residents and their families can expect that resident’s final wishes will be respected. EVIDENCE: Following the last inspection a requirement was made relating to the unsafe preparation of medicines into secondary containers, which was seen as unsafe practice. The manager at the home has addressed these concerns in a positive way. The home is in the process of changing to a Monitored Dosage System (MDS). Training for staff has begun to use the new system with training already undertaken on the 14th October and a second day planned for the 12th December 2005. There remains a need to monitor the administration of medication until the new system is fully introduced. The inspector did not on this occasion look at whether the medicine policy and procedure has been reviewed to ensure it remains relevant to the new practice. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 Page 11 The recording of medication was satisfactory with no identified gaps in the administration charts viewed. However it was clear from discussion with a senior carer and the deputy manager that there were different opinions about what should happen to medication not given. While both members of staff were clear about entering on the chart why the medication was not given there was a confusion about whether it should be left in the blister pack to be returned to the chemist or whether it should be “tagged and bagged” separately. There was evidence on resident’s files of details of their last wishes in the event of death. There was evidence that this has been completed in discussion with the resident and their family as it details when families would wish to be notified about illness and deterioration of the resident’s health. Discussion with staff confirmed that they would wish to care for a resident for as long as they could meet their needs and ensure that appropriate pain relief was available to ensure the residents comfort. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 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 the following standard(s): 12 Residents can expect to be offered a limited range of activities and outings. EVIDENCE: Discussion with staff and residents confirmed that there are few arranged activities outside of the regular Morning Prayer meeting and a weekly visit by an accordion player from the local community. It was clear from the monthly report prepared by one of the Trustees as part of the Regulation 26 visits that activities have been discussed but no further development has been made since the last inspection. Discussion with residents confirmed that they are looking forward to seasonal entertainment from the local school and the Women’s Institute (WI) during December. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 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 the following standard(s): 18 The home has a clear policy and procedure in place for dealing with allegations or suspicions of abuse but the policy needs to be updated to reflect the most recent guidelines for the county. (June 2004) EVIDENCE: The home had a protection of vulnerable adults policy, detailing the procedures to follow to safeguard residents from abuse, but they need to have an updated copy of the Suffolk Protection of Vulnerable Adults (POVA) inter agency policy, procedures and guidelines for staff. Discussion with the deputy manager indicated that they last attended an Abuse Awareness course in 2003. This training needs to be updated to reflect the updated guidance and cascaded to all staff. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 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 the following standard(s): 19, 25,26 Residents can expect to live in a clean, safe and well-maintained environment. EVIDENCE: The home has an effective security system whereby visitors have to use the intercom system to gain access to the front door. All visitors are expected to sign the visitors book on entry and when leaving. Positive action has been taken to replace a carpet in bedroom 2 and it was clear that the room has also been attractively decorated. The temperature of the hot water is monitored to ensure it is maintained to a safe temperature. The maintenance man tests the water monthly and adjusts the thermostats accordingly. None of the residents are able to bathe independently and the temperature of the hot water is tested prior to a resident having a bath. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 Page 15 The deputy manager said that if the temperature has gone below or above the safe temperature it is recorded on the residents care plan. However this does not enable the manager to see if there is a pattern to the temperature fluctuation and a central record (perhaps in each bathroom) should be maintained. Bathrooms and toilets seen during this inspection all contained liquid soap and paper towels and were clean and fresh. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 There is a recruitment procedure in place but there is a need to ensure all checks requested to confirm suitability are received. EVIDENCE: One member of staff has been recruited since the last inspection. There was evidence on their file that a Criminal Record Bureau (CRB) check has been sent and a POVA 1st check was available and evidence indicated that the member of staff did not commence their duties until this was received. Two references had been sent for but there was only evidence of one being received. It was noted that the referee talked about the applicant’s experience of working in care homes but this was not confirmed in the member of staff CV. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,36,37 Residents can expect the home to be managed effectively by a qualified manager who listens to the views of residents. EVIDENCE: The registered manager holds an NVQ level IV qualification in management and is positive about training for staff. Discussion with staff indicated that the manager does lead by example. A member of the Trust Board undertakes unannounced visits as required by Regulation33 and a copy of the report is now forwarded to the local Commission for Social Care Inspection (CSCI) office. Evidence that the home is financially viable was not available and has been subject to a requirement for the last two inspections. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 Page 18 Currently supervision is provided approximately four times a year. The supervision format enables discussion about the member of staff’s keyworker role, development and achievements. Discussion with the deputy manager indicated that staff meetings are infrequent although members of staff are asked their views during supervision and on a day-to-day basis. Daily records relating to individual residents were seen during this inspection and all seen were detailed and provided a good picture of how the resident spent their day and how they were feeling. The language in records was appropriate and respectful. All recrds seen were up to date and had been completed in ink and alterations had been crossed out rather than using corrective fluid. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X 3 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 2 X 2 3 x Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 Page 20 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 OP9 Regulation 13 (2) Requirement The procedure for storing medication not administered must be clarified with the providers of the MDS system The medication policy and procedure must be relevant to the new medication system. The registered person must ensure that a programme of activities is provided. This is an outstanding requirement from the last inspection. The Protection of Vulnerable Adults (POVA) policy and procedure must reflect the most recent guidelines and staff training must be undertaken. The registered persons must produce a business plan or equivalent document to demonstrate that the home will continue to be financially viable in order to achieve the aims and objectives as set out in the statement of purpose and as required by Regulation. This requirement is repeated from the last two inspections.
DS0000024441.V269062.R01.S.doc Timescale for action 31/12/05 31/12/05 2 3 OP9 OP12 13 (2) 16 (n) 31/12/05 4 OP18 13 (6) 31/01/06 5 OP34 25 (1) 31/12/05
Page 21 Manor House Christian Rest Home Version 5.0 6 OP29 19(5)& Sch. 2(7,9,19) There must be evidence on staff files that two written references have been sought and received. 31/12/05 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 OP25 OP29 OP36 Good Practice Recommendations A centralised record of the temperature of hot water should be maintained in each bathroom to enable the manager to monitor any fluctuation. Applicants’ employment history should be checked to ensure there are no unexplained gaps. Formal supervision should be provided at least six times a year. Manor House Christian Rest Home DS0000024441.V269062.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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