Inspection on 31/05/06 for Manor House Christian Rest Home

This inspection was carried out on 31st May 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Manor House Christian Rest Home 01/05/08

Manor House Christian Rest Home 08/05/07

Manor House Christian Rest Home 28/11/05

Manor House Christian Rest Home 20/07/05

Manor House Christian Rest Home 06/01/05

Manor House Christian Rest Home 11/08/04

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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 Christian Rest Home Bacton Stowmarket Suffolk IP14 4LJ Lead Inspector Jane Offord Key Unannounced Inspection 31st May 2006 11:30 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.V297533.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 Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 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 Jane 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.V297533.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 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 that 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 is 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. The fees for the home range between £331 weekly and £356 weekly depending on the funder. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection focussing on the core standards for the Care of Older People. It took place on a weekday between 11.30 and 15.45. The registered manager was having a final assessment with an assessor for their Registered Manager Award but was able to spend some time with the inspector. During the inspection two residents’ files and care plans were seen as well as two staff files. Training files, some policies, supervision records, medication administration records (MAR sheets) and some fire and maintenance records were all inspected. The staff rota was seen and the manager explained the system used to manage residents’ personal monies. A number of staff and residents were spoken with and a tour of the building was undertaken. A medication administration round and the serving of the lunchtime meal were observed. The home was calm and activity during the day was friendly and appropriate. Residents looked happy and well cared for. They were complimentary about the care and support the staff offer them. What the service does well: What has improved since the last inspection? What they could do better: Apart from regular prayer meetings there is little organised activity. A recent fire assessment by a consultant company highlighted some risk areas that need addressing. The bathroom downstairs needs redecorating and the bath panel made good. Identification photographs for residents need to be taken and attached to medication administration records (MAR sheets). Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 6 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 Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6. People who use this service can expect to have information about the home and an assessment of need prior to making the decision to move in. The home does not offer intermediate care. EVIDENCE: The two residents’ files seen both contained a pre-admission assessment that covered personal care, diet, allergies, sight, hearing and communication. Other headings considered included mobility and history of falls, continence, oral health and foot care. In addition there was a full mental health check covering orientation, social behaviour and mood. Four months after admission each resident completes an evaluation and there are questions about the admission process. The completed questionnaires seen were very positive. They made mention of visits to the home prior to admission, having good information about the home, being made to feel welcome when they arrived and having a newly decorated room to settle into. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. People who use this service can expect to have an individual care plan that includes health needs, be treated with respect and have their medication dealt with safely. EVIDENCE: Residents are registered with the GP surgery next to the home. Staff said that the GP visits the home every week on a Tuesday morning but they can contact them at any time if required. The community nurses also offer a good service to the home. Residents’ files and care plans seen looked at areas of health need and social activity. The care plans covered mobility, continence, oral hygiene, diet, hearing and medication. In addition there were entries for personalising their room, their preferred daily routine, social and spiritual needs and their final wishes including who to contact for making the arrangements. There were risk assessments for moving and handling, falls and using the lift. There was evidence of appointments with health professionals such as optician and chiropodist. One file contained a life history of the resident and there was evidence in both files that they were regularly reviewed. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 10 The medication administration round at lunchtime was observed. The Monitored Dosage System (MDS) packs are kept securely locked in the clinic room. Medication was administered sensitively giving residents a choice of when they wanted to take the tablets. The Medication Administration Record (MAR) sheets seen were all correctly completed, however there was no photograph of the residents for identification. The manager said they were waiting for the chemist to send additional dividers to attach the photographs to but it was the policy of the home never to use agency staff so the staff all knew the residents well. When the carer administering the medication had to leave the area another member of staff was requested to ‘keep an eye on the MDS packs’ to maintain safety. Staff were observed knocking on doors of rooms before entering. During lunchtime staff gave residents choices about where they wanted to sit and what they wanted to eat. All interactions observed were friendly and polite. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People who use this service can expect to be encouraged to maintain contact with family and friends but they cannot be assured that there will be sufficient activities offered within the home to meet their expectations. EVIDENCE: The files seen had details of the resident’s next of kin and contacts. On the day a number of visitors came and went. They were greeted warmly and spent time with residents where the resident chose to see them. The files had information recorded of the residents’ preferred daily routine such as the time they liked to get up and go to bed. One resident was heard to joke with a member of staff that they had got up just in time for lunch that day. The home has a daily prayer meeting that residents can attend or not as they choose. There is also a programme of weekly services given by visiting ministers or lay people. There is a weekly visit by an entertainer and the occasional video evening. Staff spoken with felt that there were insufficient activities organised. They tried to spend time with residents, particularly in the afternoons, and on the day of the inspection one member of staff had brought in their wedding photographs for the residents to see. That generated some animated conversation. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 12 The manager said that there was a meeting planned the following week with one of the trustees, themselves and the deputy manager to discuss initiating a programme of activities. They had recently acquired a copy of the Alzheimer’s Society’s activity book and a selection of board and card games. They hoped to set up a rota of staff for doing regular activities with the residents. Lunch served on the day was sausages with carrots, greens and potatoes. Residents were asked the size of portion they wanted. There was a dessert trolley with rice pudding, egg custard, jelly, custard, lemon curd tart, stewed fruit or bakewell tart and residents could ‘mix and match’ as they chose. Residents spoken with as they left the dining room all said they had enjoyed their lunch. One resident said they particularly enjoyed their breakfast and that day had had eggs, bacon and mushrooms. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use this service can expect that any complaint will be taken seriously but they cannot be assured that the POVA policy is linked with the most recent Suffolk guidelines or that the staff have had recent training in POVA. EVIDENCE: The CSCI has not received any complaints about this service since the last inspection. The compliments/complaints log for the home was seen. It contained a good number of compliments but the service has not received a complaint recently. The service has a robust complaints policy that is available to residents. Staff spoken with were clear about what they would do if they had any evidence of a potentially abusive situation in relation to a resident but they had not had any recent training. The training records confirmed that POVA training had generally been done four to five years ago. The POVA policy for the home needs to be updated in line with the Vulnerable Adult Protection Committee guidelines for Suffolk of June 2004, and cross-referenced to them. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 26. People who use this service can expect to live in a clean home with their own possessions but they cannot be assured that there is a programme of ongoing maintenance. EVIDENCE: Manor House is an attractive listed building with high ceilings and lovely rural outlooks. The gardens are well maintained and have areas for outdoor seating, which staff said are used in the good weather. Residents’ individual rooms were seen and were all different in size and outlook because of the layout of the house. Some residents had chosen to have their own furniture in their rooms; others had decided to have their own bed linen. Everywhere was clean and homely. The laundry was seen and is kept locked when there is not a member of staff working in there. The Control of Substances Hazardous to Health (COSHH) regulations were kept in a folder in the laundry for staff reference. The training files showed staff had had COSHH instruction. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 15 The manager explained that the trustees undertake most ongoing maintenance and they leave messages for them about jobs that require attention. The manager said there is a problem in that the trustees are not available on a daily basis so some jobs are not done as rapidly as they would like. The décor throughout most of the home was in good order but the downstairs bathroom badly needs redecoration and the bath panel needs refixing. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use this service can expect to be cared for by competent, welltrained staff who have been recruited correctly. EVIDENCE: Two staff files were seen. They both contained evidence of identification checks in the form of birth certificate or passport photocopies and relevant references. One file did not contain a CRB check although there was a POVA 1st check. The manager said that one had been requested but they were taking so long to come through at the moment. They had enquired again that day and been given a new contact number to pursue it. Staff rotas were seen and showed that there were 3-4 carers each morning with 2 carers to cover a late shift and nights. In addition the manager was rostered most weekdays and there was a domestic on weekdays and two cooks. Training files were seen and showed that staff receives training in moving and handling, health and safety, medication administration, first aid, fire safety and COSHH. Some additional sessions on death and dying, continence, diabetes and dementia have been given too. The home employs twenty staff. Six staff have achieved their NVQ level 2 with a further four working towards it. Four staff have NVQ level 3 and two more will be enrolling soon. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 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, 35, 36, 38. People who use this service can expect that it is run in their best interests, that their financial affairs are safe and that the staff are supervised. They cannot be assured that all aspects of their health and safety are protected. EVIDENCE: The manager has been employed in the home for a number of years, initially as a carer, later promoted to assistant manager and three years ago to registered manager. They hold an NVQ level 3 and on the day of inspection the assessor confirmed that they had successfully completed their registered manager’s award. The manager explained the system used to manage the residents’ personal finances. Each transaction is clearly logged and receipts are numbered so there is an audit trail. One resident’s balance was randomly checked and did not, initially, tally with the running total. The manager checked the running total and found a calculation error that meant it was correct. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 18 The home, as well as conducting a post admission survey of the residents, also does an annual survey of the residents’ satisfaction with the home and the service being offered. The last survey was last July and the manager is preparing to do a further survey in the next month or so. Staff files seen had records of supervision sessions with senior staff. The notes covered a wide range of subjects. Staff spoken with confirmed they had supervision every two months and that the agenda was set jointly. They felt comfortable and able to discuss any issues relating to their work and development. The manager talked about changes needed in the kitchen. The gas installation had been checked by a CORGI registered engineer who said that as the kitchen had no external access a gas cooker of the size there was unsafe. There are plans to change to an electric cooker imminently. The home has recently had a fire risk assessment done by an external consultant group. A number of requirements were made including not wedging fire doors, not using an extension cable for the kettle in the staff room and removing combustible materials from the generator shed. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 1 Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 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 A photograph for identification must be attached to the MAR sheets. A programme of activities must be implemented. This is a repeat requirement. The Protection of Vulnerable Adults (POVA) policy and procedure must reflect the most recent guidelines and staff training must be undertaken. This is a repeat requirement. The requirements of the fire risk assessment undertaken by an external consultant group must be met. The work required to make the kitchen safe must be undertaken urgently. Timescale for action 19/06/06 2. OP12 16 (2) (n) 30/06/06 3. OP18 13 (6) 31/07/06 4. OP38 23 (4) (a) (c) 31/07/06 5. OP38 16 (2) (g) 23 (2) (c) 30/06/06 Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 Page 21 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 OP19 Good Practice Recommendations Consideration should be given to obtaining the services of a dedicated maintenance person to ensure all maintenance work is undertaken in a timely way. Manor House Christian Rest Home DS0000024441.V297533.R01.S.doc Version 5.2 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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