Inspection on 27/06/06 for Manor House (The)

This inspection was carried out on 27th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

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Snydale Care Home

Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Manor House (The) White Gap Road Little Weighton Nr Beverley East Yorkshire HU20 3XE Lead Inspector Ann Day Unannounced Inspection 27th June 2006 12:40 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 (The) DS0000066138.V300747.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 (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor House (The) Address White Gap Road Little Weighton Nr Beverley East Yorkshire HU20 3XE 01759 388355 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) Park Lane Healthcare (The Manor House) Ltd Care Home 38 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (38), Old age, not falling within any other of places category (38) Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2005 Brief Description of the Service: The Manor House is a tastefully converted Victorian farmhouse standing in its own well-stocked and well-tended grounds of some two acres in the village of Little Weighton, near Beverley. The proprietors and staff pride themselves in maintaining a family atmosphere. The home has two floors with a passenger lift to provide access to the first floor. Many of the bedrooms have views over the surrounding countryside and spacious gardens. There are three lounges and a separate dining room. A large conservatory provides access to outside areas where service users can sit and enjoy the gardens. The home is registered for up to 38 older people, including those with dementia related conditions. Fees £330-£650. Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included preparation, collation of information received, a pre inspection questionnaire completed by the providers of this service and fieldwork. The fieldwork included a tour of the premises, case tracking individual residents following their experience of the care provided; examination of statutory records; observation of and meeting with residents; interviewing staff members and the manager. The site visit to the home took place on 27th June 2006 and was unannounced. Fieldwork took a total of 5 hours to complete. What the service does well: What has improved since the last inspection? The new owners have had code locks fitted to both external doors to further improve security; the locks are linked to the fire alarm system. . A laundry assistant is employed 3-4 days per week; this has been introduced since the change of ownership, giving carers more time with service users; and laundry equipment has recently been replaced. Staff said, “Nice family atmosphere, more caring about the people; things have, been improved”. Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 6 The home has recently increased staffing on night duty by one, to ensure that individual service user’s needs are met. There are regular staff meetings, members of staff have been provided with lockers, and a smoking area for those staff members who smoke. Members of staff said that the management is very approachable. “Since the change of ownership things seem to get done. Mr Mitchell is very approachable, staff training has improved.” 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 (The) DS0000066138.V300747.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 (The) DS0000066138.V300747.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. However, the pre admission assessment procedures would benefit from some improvement. EVIDENCE: The home has an updated comprehensive Statement of Purpose and Service User Guide. The manager confirmed that individual contracts for the residents are kept at the organisation’s head office. Service users’ case files were examined and currently pre-admission assessments are not completed for every new resident, as required; this was brought to the attention of the newly appointed manager. The home does not provide intermediate care. Manor House (The) DS0000066138.V300747.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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Practice regarding the planning and delivery of care means that all service users can be sure that their health and personal care needs will be fully met. EVIDENCE: Members of staff were able to explain how they ensured individual resident’s dignity and privacy whilst providing personal care. The interaction and rapport between members of staff and residents was seen to be very good. Staff said, “Nice family atmosphere, more caring about the people; things have been improved”. Three service users were case tracked, following the care needed and provided for these individual service users. In addition care records for residents, who had or were currently receiving pressure area care from district nurses and staff in the home, were examined. Care records were found to be comprehensive, including risk assessments, detailed care plans, which are evaluated and regular reviews of individual care needs are documented. Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 10 One resident was taken ill during the visit, an ambulance was called; the resident was taken to hospital, accompanied by a member of staff and all necessary documentation. The medical emergency was dealt with professionally and sensitively. The home has Safe Handling of Medication procedures in place and safe practices are adhered to. The home uses a monitored dose system, for the administration of medication. The manager ensures that only appropriately trained members of staff administer medication. Medication Administration Record sheets were examined and were found to be accurate. Manor House (The) DS0000066138.V300747.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities within the home and community mean the service users do have a range of opportunities to participate in stimulating and motivating activities. Meals and mealtimes are not rushed and are an enjoyable, social occasion for all of the service users. EVIDENCE: The home employs a part time activities coordinator, and there is a published varied programme of activities made available for residents to participate in. All activities are individually care planned and recorded; members of staff promote the continuation of regular visits, e.g. church; particularly where these visits or activities were established patterns before an individual’s admission to The Manor. Staff have organised a summer fete, cream teas involving residents’ relatives; Morris dancers, stalls, raffle for residents’ funds; are all part of the plans for this year’s fete. Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 12 There has been a series of residents’ outings e.g. Snow White on Ice; and the home provides regular weekly sessions of Bingo and a Quiz. The home encourages open visiting, observation and service users confirmed that family and friends are made welcome. A male carer on the staff team enables male residents to choose to have care provided by a carer of their own gender, increasing their choices. The home has a Key worker system in place that works well. Staff members said, ”Residents are all different, choice at mealtimes, able to change their minds, residents likes and dislikes are listed on the kitchen wall.” Teatime sandwiches, fishcakes, pizza, hot meals during the week, enough to eat, more if they want. Manager confirmed: Currently there are two cooks; Cook prepares teatime meal, before leaving for the day, a member of care staff is allocated kitchen duty during the evening. Recently, concerns regarding food provided was addressed at the Residents and relatives Committee meeting. Karen Bird, the manager is currently reviewing the cook’s work schedule to ensure that individual service users needs are met. Service users confirmed that they liked the food, however, one resident said that they would prefer less cabbage on the menu. Manor House (The) DS0000066138.V300747.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): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel safe and listened to. Formal processes have been developed and the home’s procedures are available, understood and consistently applied. EVIDENCE: The home has policies and procedures in place; service users, relatives and members of staff know to whom they speak if they have any concerns. Members of staff have attended adult protection awareness training, and are clear about their responsibilities, with regard to the reporting of any incident, occurrence or concern. The home had one adult protection investigation during November 2005, which was dealt with appropriately, adhering to the home’s own, and the local authority’s policy, procedures and guidelines. Since this investigation the security of the home has been improved significantly by the installation of close circuit television. The CCTV scans the doors and corridors, residents privacy and dignity is not at risk. Day to day concerns expressed by residents, or their relatives are dealt with directly, or are raised at the regular “Residents and Relatives’ Committee”. The home has not received any written complaints since the last inspection. Manor House (The) DS0000066138.V300747.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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The maintenance and renewal of equipment and facilities mean that service users live in a safe environment. The very good condition of the décor and fixtures and fittings means that service users live a good environment. Security has been significantly improved to safe guard all residents and staff. EVIDENCE: A tour of the premises was undertaken, aids and adaptations are in place to promote residents’ independence. The home was very clean, comfortable and homely in appearance. Residents eat in a convivial atmosphere. The home has an infection control policy in place; the home is free from malodour. The home’s toilets have been fitted with alcohol gel (cleaning Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 15 hands); racks for disposable gloves and personal hygiene products are accommodated in a discreet manner. Laundry equipment has been recently replaced in the home. The home’s maintenance record was available for examination. Small items were identified within the maintenance book- mould on tiles between floor and ceiling of a shower room and wallpaper missing from a window in a service user’s bedroom. (To date the service user had declined to have the wall paper replaced after the window was replaced.) The current manager has moved her office into the downstairs office with the closed circuit television monitor, to increase her availability and accessibility; previously the manager’s office was located upstairs. In addition to the provision of closed circuit television, the new owners have had code locks fitted to both external doors to further improve security. The rooms of those service users whose care was case tracked (individual experience of care provided was followed) showed individuals had been able to personalise their rooms, and they were satisfactorily clean and well presented. Service users felt their rooms were comfortable. Aids and equipment were provided in the home, all of these were of a satisfactory quality. The stock of general aids, were in a good condition. The hoists were serviced regularly, which ensures the safety of and minimises risk for people who use the service. The manager said that she is having new signs made for individual rooms to improve identity, including symbols/pictures for bathrooms and toilets. There was a menu board and reality board in the dining room, to ensure that service users, are enabled to make informed decisions. Manor House (The) DS0000066138.V300747.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 The quality rating for this outcome group is good. This judgement has been made using available evidence including a visit to this service. The home’s staff are competent and appropriately trained, ensuring that service users are in safe hands at all times. EVIDENCE: The manager, assistant manager and three members of staff were interviewed. All four staff files, induction training records and staff rosters examined were comprehensive and in good order. Staff recruitment practices have improved. Files of long-service members of staff do not currently contain two written references; the manager was advised to complete references for these staff members. Members of staff interviewed were clear about their role, knew what was expected from them and showed a good understanding of the actions they needed to take to meet and promote independence, equality, diversity and choice. A laundry assistant is employed 3-4 days per week; this position has been introduced since the change of ownership of the home, giving carers more time with service users. Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 17 A care worker confirmed that all the statutory checks had taken place before she started work at The Manor. Staff members and documentation confirmed that training, supervision and appraisal are regularly provided; and that several members of staff are currently undertaking NVQ Level 2. There are plans to provide staff training in the care of people with dementia, in the near future. The home has recently increased staffing on night duty by one, to ensure that individual service users’ needs are met. Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 18 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current management arrangements are meeting the needs of the service, and the quality of the service is good. EVIDENCE: The newly appointed manager has achieved NVQ Level 4, & “The Registered Manager’s Award” (RMA), is currently undertaking the NVQ Assessors course, and is to apply to be registered with the Commission. The manager confirmed that she and the home’s staff are able to deal directly with Mr Chris Mitchell, the Responsible Individual. Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 19 There are regular staff meetings, members of staff have been provided with lockers, and a smoking area for those staff members who smoke. Private transport is provided for staff members, to and from duty, at a small cost, in the absence of local transport. Members of staff said that the management is very approachable. “Since the change of ownership things seem to get done. Mr Mitchell is very approachable, staff training has improved.” Payments for the hairdresser and chiropody services are invoiced. Currently residents’ personal money is held in separate envelopes, which are signed and sealed, and securely stored. Individual personal money balances were checked; and were found to be accurate. The manager was advised to ensure that all transactions are countersigned. A Relatives and Residents’ Committee meeting is held regularly; it is chaired by a relative and attended by the Responsible Individual, Mr Chris Mitchell. The manager, attends the committee at the request of members, and gives feedback on issues previously raised by the committee, with any action taken identified. The benefits were discussed, of sending out questionnaires to those relatives who do not attend the regular “Relatives’ and Residents’ Committee” meetings; or to hold a set session with the manager to encourage relatives to raise concerns promptly so that they can be addressed in as shorter timescale as possible. Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 20 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 2 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation Reg. 14 Requirement The registered person shall not provide accommodation to a service user unless the needs of the service user have been assessed by a suitably qualified/trained person, and a copy of the assessment is obtained and made available for examination. Timescale for action 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP31 OP33 Good Practice Recommendations The manager should apply to be registered with the Commission at their earliest convenience. Further engage relatives who do not attend the Relatives & Residents Committee meetings, by sending out questionnaires, or holding a session to meet with the manager. Ensure that personal money transactions and balances are countersigned. 3 OP35 Manor House (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 (The) DS0000066138.V300747.R01.S.doc Version 5.2 Page 23 - 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. 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