CARE HOME ADULTS 18-65
Manor Mews Manor Mews Cowick Lane Exeter Devon EX2 9JG Lead Inspector
Susan Lyons Unannounced Inspection 16th January 2006 11:01 Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 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 Mews DS0000059978.V277969.R01.S.doc Version 5.1 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 Adults 18-65. 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 Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Manor Mews Address Manor Mews Cowick Lane Exeter Devon EX2 9JG 01392 438048 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) sally.cross3@btinternet.com Mrs Sally Ann Cross Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 22nd August 2005 Brief Description of the Service: Manor Mews provides accommodation and care for up to ten adults who have a learning disability a number of who have lived there for over 10 years. It is situated close to local bus routes into the city. The owner lives on site and is supported by the staff team. The home is a large detached Georgian style property that stands in large well maintained gardens. The building is decorated in a homely manner with contemporary furniture and fittings. Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspector arrived at the home at 3.10pm. Much of the time was spent talking to residents about how they felt about living at the home. The inspector also looked at some records and spoke to the two members of staff on duty and the manager. The inspector left the home at 6.30pm. Most of the core standards were inspected at the last inspection on 22nd August 2005 therefore the report for that inspection needs to be read as well as this one. There was a nice relaxed feeling within the home with residents joking amongst themselves and with the staff. What the service does well: What has improved since the last inspection? What they could do better:
It was noted that an incident had occurred within the home, which the Commission for Social Care Inspection had not been notified of under Regulation 37. Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 6 Details of a specific restriction agreed with a care manager need to be documented in the care plan and risk assessments need to be in place for all uncovered radiators. Staff need to continue with NVQ qualifications so that 50 of the staff are appropriately qualified. 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 Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This core standard was assessed on 22nd August 2005. EVIDENCE: Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&7 With one small adjustment the care plans will adequately provide staff with the information they require to support residents. Resident’s choice is recognised and acted upon. EVIDENCE: Care plans were looked at in detail at the last inspection. However through discussion it was noted that a restriction which the manager had agreed with the care manager, of the resident, was not recorded on the individual care plan. Residents said that they have meetings to discuss anything they like and that they are asked about what food they want to have. The inspector saw a resident being asked what they would like to eat that evening as an alternative to what was on the menu. Residents also said that they go shopping with staff to choose their own clothes and that they choose what to wear each day. Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These core standards were assessed on 22nd August 2005 EVIDENCE: Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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 Personal support within the home offers residents choice and independence. EVIDENCE: Residents said that they are able to go to church if they want to and details of this were seen on individual care plans. Details of how personal care is to be provided are detailed in the care plans and some residents were able to describe what support they receive from staff. Additional support from health professionals is provided when it is required. Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These core standards were assessed on 22nd August 2005 EVIDENCE: Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The standard of cleanliness within the home is good offering residents an attractive and clean place to live. EVIDENCE: Currently residents do not do their own personal washing. The home has a laundry which meets the needs of the home. On the day of the inspection the home was clean and tidy and there were no unpleasant odours. Residents told the inspector that they did not have to clean their rooms themselves as the staff did it for them. Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Progress is being made to ensure that residents benefit from having the support of appropriately qualified staff. EVIDENCE: Currently the home has one member of staff with NVQ level 2 and 3 and one member of staff who has just finished level 2. Two members of staff are completing level 3, one member of staff is completing level 4 and one completing level 2. So although they have not yet reached the 50 of staff trained to NVQ level 2 they are working towards it. Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The resident’s benefit from a qualified manager who is supportive of staff. Safety in relation to hot surfaces may be compromised until specific work is completed within the home. EVIDENCE: The Registered Provider who is also responsible for the day-to-day management of the home has obtained NVQ level 4 and the Registered Managers Award. Staff who spoke to the inspector said that they found the manager approachable and supportive. A recommendation was made following the last inspection that all radiators are covered. There are three remaining in bedrooms to cover and the material has been obtained for them. An individual risk assessment needs to be in place in relation to the uncovered radiators. Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X 3 X X X X 1 X Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 17 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. 2 Standard YA42 X Regulation 13 (4) (c) 37 Requirement Timescale for action 19/02/06 You are required to complete individual risk assessments on all uncovered radiators. Incidents affecting the well being 19/02/06 of residents should be reported to the Commission. 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 YA6 YA32 YA42 Good Practice Recommendations It is recommended that any restrictions made in relation to a residents should be documented in the care plan. It is recommended that staff complete their NVQ qualifications. You are recommended to cover all radiators Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Manor Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 19 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 Mews DS0000059978.V277969.R01.S.doc Version 5.1 Page 20 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
