This inspection was carried out on 26th September 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.
CARE HOMES FOR OLDER PEOPLE
Manor Park off Catcote Road Greenock Road Hartlepool TS25 4EU Lead Inspector
Stephen Willcock Announced Inspection 26th September 2005 10.00 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 Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Manor Park Address off Catcote Road Greenock Road Hartlepool TS25 4EU 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) 01429 274122 01429 273472 Four Seasons Healthcare (England) Limited (Wholly owned subsidiary of Four Seasons Health Care Ltd) Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. To allow the admission of one named individual under the age of 65 years. To allow the admission of up to 5 service users aged 50 years plus with physical disabilities (PD). 25th April 2005 Date of last inspection Brief Description of the Service: Manor Park is a care home registered with the Commission for Social Care Inspection for personal care and nursing. The home is situated close to local amenities and shops. It is a two storey purpose built home. Passenger lifts provide access to the first floor. The home offers a range of lounges and dining areas for service users and visitors. Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place on 26th September 2005 over a period of 6 hours. During the inspection time was spent talking to service users, relatives, staff and management. A number of records were looked at and the building and grounds were also inspected. Discussions with service users and their relatives found a high degree of satisfaction with the care provided and the rapport that had developed between themselves and the staff. One service users relative was not as happy with the care provided and said he was willing to discuss this with the new manager. The issue of activities was generally raised by service users who were concerned that there had been a reduction of the activities provided since the activities co-ordinator had left the home. Manor Park had recently undergone major changes in the staffing complement due to a high number of staff leaving to take up employment at a nearby home that had recently opened. However, the management of the home had ensured that staffing levels remained appropriate and service users and relatives reported no reduction in the quality of care provided. Since the last inspection a new manager had been appointed and it is hoped that a period of stability will follow from this appointment. What the service does well: What has improved since the last inspection?
Since the last inspection documents and policies that were highlighted for amendment had been attended to and a quality assurance survey had been arranged. Authorisation to provide a patio area that was much needed was still being sought but it was expected that work could commence when this was received. A new manager is now in post and demonstrated an eagerness to carry out her role and to enhance service users experience of living at the home. Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 6 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 Park DS0000000186.V252107.R01.S.doc Version 5.0 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 Park DS0000000186.V252107.R01.S.doc Version 5.0 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): 4, 5 and 6 The home provides service users information to help make the decision to live at the home and offers a trial visit. EVIDENCE: In discussion, service users and relatives said their needs were met and they were generally satisfied with the care that they received, however one relative expressed some concerns but said he was willing to discuss these with the new manager. Service users care plans were looked at and found to contain assessments and reviews of care needs. A policy, offering prospective service users a visit to the home before making the decision to live there, was in use. In discussion, service users said that they were given the opportunity to visit the home prior to admission and to have a trial period. The home did not offer intermediate care. Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 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): 8 and 10 The home ensures that service users health needs are met and staff treat service users with dignity and respect. EVIDENCE: The home carries out care planning alongside the service user needs assessment to ensure that any specialist equipment identified is provided. One service user talked about problems she had with a pressure relief mattress but was confident that the new manager would take action to have it put right. Service users files showed access to health care services such as doctors and chiropodists appointments being made when needed. In discussion, service users said they were treated well and always with respect. There was some concern raised about the number of staff changes recently and that a new manager had been appointed but there was agreement that the existing staff had coped very well in the interim period and that “things were starting to pick up”. Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 10 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): 13 and 14 The home encourages service users to maintain their social contacts and encourage them to retain control over their lives. EVIDENCE: In conversation with service users and relatives it was found that visitors to the home were encouraged to visit their relatives at any time. One visitor to the home said the home was “very clean and the staff are very nice” and she could always meet with her friend in private. Service users spoken to said that they could make choices in their lives including when to get up and go to bed but added that there was little in the way of activities at present as the home activities co-ordinator had left the position. It was seen that some service users had brought their own possessions to the home to make their bedrooms as homely as possible. Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home operates a satisfactory adult abuse awareness policy. EVIDENCE: The home has a policy and procedure on Adult Abuse and has recently updated their procedures to follow the protection of vulnerable adults protocol “No Secrets”. The new manager was able to demonstrate full awareness of the procedures to be followed in the event of an incident occurring at the home. Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 12 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): 21 and 23 The home provides suitable toilet and washing facilities and bedrooms meet service users needs. EVIDENCE: There are a number of toilets and bathrooms equipped with specialist bathing equipment, situated close to bedrooms and communal areas and in addition some of the service users bedrooms have en suite facilities. The home also has separate sluice facilities. In discussion, service users generally agreed that their bedrooms met their needs and were seen to be personalised to their choice and taste although one service user felt that redecoration was needed. Some of the service users had brought in their own furnishings, TV’s, Stereo’s, fridges, ornaments and pictures. Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 13 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 and 30 The home provides staff with satisfactory training to do their jobs and carries out robust checks prior to employment at the home. EVIDENCE: The home had recently undergone a shortage of staff as many had sought employment at a newly opened home in the area. The remaining staff had been aided by agency staff and care workers from another within the same care group. Service users said that the care given during this time had not been reduced and paid compliments to the remaining staff for providing a high level of care. Examination of staff files found evidence of satisfactory checks being carried out prior to the commencement of employment including Criminal Records Bureau checks and Protection of Vulnerable Adults checks. Staff training was ongoing and recent courses included fire training, moving and handling, safe handling of medications and peg feed training in addition to study leading to the achievement of NVQ2 in care. Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 14 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 and 38 The management arrangements at the home are satisfactory and Health and Safety is given full attention. EVIDENCE: The home has undergone two recent changes in management and the current manager is to apply for registration with the Commission for Social Care Inspection. The current manager is a qualified 1st level nurse and has much experience in the care field. The manager, although holding NVQ3 in management, would need to achieve NVQ 4 in management. The regional manager and an experienced manager from another home are currently providing support and supervision to the new manager. Health and Safety records and checks were satisfactorily maintained and training in fire safety had been organised.
Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 2 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X 3 X 3 X X X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 3 Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 16 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. Standard Regulation Requirement Timescale for action 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 OP13 OP31 Good Practice Recommendations The manager should ensure that activities are offered to service users regularly. The manager should undertake study leading to achieving NVQ4 in management. Manor Park DS0000000186.V252107.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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