Inspection on 22/08/05 for Manor Mews

This inspection was carried out on 22nd August 2005.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Mews 07/10/08

Manor Mews 01/11/06

Manor Mews 16/01/06

Manor Mews 24/01/05

Manor Mews 02/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Manor Mews Cowick Lane Exeter Devon EX2 9JG Lead Inspector Susan Lyons Announced 22 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Manor Mews Address Cowick Lane, Exeter, EX2 9JG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01392 438048 Mrs Sally Ann Cross Care Home 10 Category(ies) of LD Learning Disability (10) registration, with number of places Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24 January 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 D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon. The inspector was able to meet all of the residents with the exception of one. Residents gave the inspector a lot of information about the home and what it was like to live there. Within the house there is a homely and relaxed atmosphere with residents joking amongst themselves and with staff. Information was also gained from discussion with the proprietor/manager, staff and looking at documentation. What the service does well: The home has undertaken their own assessments and also produced a Statement of Terms & Conditions for each resident. Residents were able to visit the home prior to moving in. Care plans contain details and guidelines to ensure that residents are supported in the same way by all the staff. Risk assessments are available which both identify personal risk and also risks associated with the home and grounds. There appears to be a range of activities available for residents to undertake and some also do voluntary work outside of the home. Where possible residents are supported to travel independently and use public transport. Good use is made of local community facilities. Residents are able to have visitors to the home and sometimes the home will take a resident to see their family to maintain contact. This is considered to exceed the standard and therefore is reflected in the score. Residents confirmed that their individual independence and privacy is maintained. Health professionals are consulted as they are needed. Residents know who they would speak to if they were unhappy about something in the home and staff are aware of adult protection procedures. The house is homely and well decorated with domestic style furniture. Staff training within the home is seen as important and this includes fire safety training. Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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 Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 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 standard(s) 2, 4 & 5 In-house assessments ensure that staff are aware of residents needs. The provision of information given to residents ensure that they are able to make an informed choice about living at the home. EVIDENCE: There have been no new admissions to the care home for some while. Inhouse assessments were seen on individual files and the manager understands that for any new referral made through a care manager she must obtain a copy of the shared assessment. Residents confirmed that they had been able to visit the home prior to moving in. Copies of the Statement of Terms & Conditions were seen on individual files. Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 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 standard(s) 6 & 9 There is clear and consistent, resident involved care planning in place which adequately provides staff with the information they need to meet residents needs. The identification and management of risk protects residents EVIDENCE: Residents confirmed that their individual care plans are discussed with them and evidence was seen on some care plans where residents have signed them. The care plans have details about living skills and this includes all the individual care needs and how they are to be met and a plan of objectives which are very focused on the individual residents aspirations. Individual risk assessments are contained within the care plan file and more general risk assessments to do with the house and grounds are available too. Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 15 & 16 The provision of activities is well managed, creative and provides variation and independence to residents. Links with the community are good enriching residents social opportunities. The home has created an environment which supports residents with family and friend relationships. Residents choice, privacy and right to independence is recognised and acted upon. EVIDENCE: Residents are able to participate in some sheltered work for an external company, within the home if they wish. Some residents described the voluntary work they undertake outside of the home and previous courses they have undertaken. Some residents also attend an arts and crafts club and a drama therapist comes into the home on a regular basis. Two of the residents described how they had been out on the bus the previous day, together, and had a cream tea. They said that they go to shops, to the building society and visit pubs and restaurants. Where possible residents go out independently and details of risk assessments in relation to this were seen. Residents confirmed that they are able to invite visitors to the home and the inspector was also informed that they do provide transport for some residents to visit their family if it is required. Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 11 Residents confirmed that their mail is given to them unopened and that they are able to have a key to their own room if they wish. They also said that staff knock on their doors before entering. Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19 & 20 The systems for maintaining resident’s medical needs and the administration of medication are good but lack of attention to detail in one area may compromise this. EVIDENCE: Residents confirmed that they all have a doctor who they see if they are unwell. The records confirm that other health specialist are consulted regularly or when they are required. Health professionals have been involved with drawing up some guidelines for staff to use in relation to one individual resident. Currently none of the residents manager their own medication. The medication is supplied in a monitored dosage system from a local pharmacy and apart from two recently recruited members of staff all staff have received training in the administration of medication. They have also received training in the administration of invasive medication which is prescribed for one resident. Medication is stored in a metal cupboard and the record of administration was seen to be in order apart from where changes have been made. This should be signed by two members of staff. Unused medication is returned to the pharmacy and a record maintained of it. Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 22 & 23 Residents are protected by the complaints and adult protection procedures. EVIDENCE: Residents named people outside of the home whom they would talk to if they had any concerns about the home. One service user was able to confirm that he had been given a copy of the complaints procedure. The home has received no complaints. The home has the ‘No Secrets’ video for staff to watch and the member of staff who spoke to the inspector was aware of what action to take if she saw a resident being treated inappropriately. Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 24 The standard of the environment within this home is good providing residents with an attractive, clean and homely place to live. EVIDENCE: The home is well decorated and maintained and on the day of the inspection was clean and there were no unpleasant odours. One resident confirmed that he was able to choose between two wall papers when his bedroom was redecorated. Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 & 35 Residents safety may be compromised by incomplete recruitment practice. Residents benefit from the commitment to training within the home. EVIDENCE: The recruitment documents were seen for the two most recently recruited members of staff. It was noted that one new member of staff had not had a CRB (Criminal Records Bureau) check completed since starting at the home. Staff are completing the induction and foundation course which is LDAF (Learning Disability Award Framework) accredited. All staff apart from the new staff are undertaking NVQ training at either level 2 ,3 or 4. Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 Views sought from all involved and analysis of the results will ensure that there is a clear vision for the home. Safety in relation to hot surfaces may be compromised until specific work is completed within the home. EVIDENCE: Questionnaires in relation to the quality of the service have been sent out and received back from professionals who visit the home, relatives and residents. The findings now need to be put into a report a copy of which should be sent to the commission. Fire records were seen and they indicate that staff are up to date with fire safety training and that the fire safety checks are being completed within the required timescales. The last member of staff to be recruited confirmed that she had been told about the fire safety of the home on her first day of work. Dates supplied by the home indicate that safety checks on fire and electricity have been completed this year as well as checks on the hoist and wheel chairs. Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 17 A recommendation was made following the last inspection that radiators are covered. These are being done over a period of time. Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 4 3 x Standard No 31 32 33 34 35 36 Score x x x 1 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Manor Mews Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 1 x x 2 x D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 19 NA 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 YA34 YA34 Regulation 19 (1) (b) 24 (2) Requirement You are required to ensure that all new staff have a current CRB & POVA check completed. You are required to produce a report in relation to the monitoring of the quality of care at the home and send a copy to the Commisssion. Timescale for action 22-9-05 31-10-05 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. Refer to Standard YA20 YA42 Good Practice Recommendations It is reccommended that when changes are made to medication information on recording sheets it is signed by two members of staff. You are recommended to cover all radiators Manor Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Suite 1, Renslade House Bonhay Road Exeter EX4 3AY 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 Mews D54-D06 S59978 ManorMews V236212 220805 Stage 4.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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