Inspection on 28/10/08 for Manor Park Care Home

This inspection was carried out on 28th October 2008.

CSCI found this care home to be providing an Good service.

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 Park Care Home 14/10/09

Manor Park Care Home 03/11/06

Manor Park Care Home 26/09/05

Manor Park Care Home 25/04/05

Manor Park Care Home 25/10/04

Manor Park Care Home 14/06/04

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Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Manor Park off Catcote Road Greenock Road Hartlepool TS25 4EU     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jane Bassett     Date: 2 8 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 25 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 25 Information about the care home Name of care home: Address: Manor Park off Catcote Road Greenock Road Hartlepool TS25 4EU 01429274122 01429273472 manor.park.manager@fshc.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Four Seasons Healthcare (England) Limited (Wholly owned subsidiary of Four Seasons Health Care Ltd) Name of registered manager (if applicable) Type of registration: Number of places registered: care home 58 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of users who can be accommodated is - 58 The registered peson may provide the following category of service only Care home with nursing - Code N To service users of the following gender - Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP, maximum number of places 58 Dementia Code DE, maximum number of places 18 Physical disability - Code PD, maximum number of places 5 Date of last inspection 18 0 5 Over 65 0 58 0 Care Homes for Older People Page 4 of 25 Brief description of the care home 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. Care Homes for Older People Page 5 of 25 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 Star. This means the people who use the this service experience good quality outcomes. This inspection was a key inspection. As a key inspection, all of the key standards were looked at or discussed. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standard regulations say it must. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 6 of 25 The inspection was carried out by one inspector. The inspection lasted a total of five hours. During this time the inspector looked at a range of documentation including service user and staff files. The inspector spoke to four service users, three staff members and the manager. The manager of the service completed an Annual Quality Assurance Assessment (AQAA). Six service users and four staff returned surveys to CSCI. The manager has recently taken up the position at the home. At the time of the inspection the home was providing services to eighteen older people. Fees at the home range from 403 to 521 pounds per week. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 25 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 25 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has procedures that should ensure that prospective service users have their needs assessed. Evidence: During the visit the inspector examined information gathered for a prospective new service user. During discussion with the manager she was able to describe the process followed to obtain information about prospective service users needs including an assessment from the care manager of that person if funded by a local authority. Service users or their representatives are encouraged to visit the home prior to moving in. The home does not offer intermediate care. Care Homes for Older People Page 10 of 25 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual need. The principles of respect, dignity and privacy are put into practice. Evidence: During the visit the inspector examined the files of three service users. Two of these files were for people receiving personal care and one for a person receiving nursing care. At the time of the inspection there were no service users accommodated in the dementia care unit. Each file contained records of assessments and reviews including activities of daily living, moving and handling, falls risk, continence, nutrition and risk of pressure damage. Files were seen to contain plans of care in relation to physical health care needs. These contained good information regarding the care needed, the persons abilities and what staff assistance was required. All files seen contained information that indicated service users have access to GPs and other health professionals as needed. Care Homes for Older People Page 11 of 25 Evidence: Staff who spoke to the inspector were able to demonstrate a good knowledge of individuals needs and how these are met. Staff spoke of promoting individuals privacy, dignity and Independence. Service users who spent time with the inspector confirmed they were generally happy with how the care is given. One person said the staff are very good. The inspector observed good interactions between service users and staff. Information contained in surveys returned to CSCI indicated people were generally satisfied with the care they receive. Information in the AQAA returned to CSCI indicated the home has a policy and procedure in relation to safe handling of medication. A recent audit carried out by a PCT pharmacist found no major concerns. A sample audit of Medication Administration Records (MAR) examined by the inspector were seen to be completed with no gaps in entries. However hand written entries of details of medication and method of administration did not contain the signature of the person making the entry or the signature of a second person confirming the accuracy of detail. The inspector was told medication is administered by either qualified nursing staff or senior care staff who have completed safe handling of medication training. The manager told the inspector that further training in safe handling of medication is planned for November 2008 and it is her intention to commence annual competency checks. Care Homes for Older People Page 12 of 25 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The food at the home is of a good quality, well presented and meets the dietary needs of the people who use the service. People who use the service are able to make choices about their lifestyles. Social, cultural and recreational activities are limited. Evidence: Service users who spent time with the inspector all expressed satisfaction with the support they receive from the staff and their lifestyles within the home. People said they were given choice in daily activities and could spend their time as they wished. One service user told the inspector I can please myself what i do. Care staff have been carrying out activities. An activities coordinator has recently been employed. Service users files seen by the inspector contained records of social activities individuals have participated in. The inspector was told activities have been limited due to service users frailties and staff availability, however activities that have taken place included bingo, dominoes and entertainers. A number of service users were expecting to attend a social evening and quiz at a local public house on that evening. Service users who spent time with the inspector told her visitors were always welcome, staff are friendly and approachable. Care Homes for Older People Page 13 of 25 Evidence: All who spoke to the inspector said the meals were of a good standard and there was a good variety and choice. One service user said the food is good, we have a choice at most meals. Information contained in surveys returned to CSCI indicated people were generally satisfied with their lifestyles within the home and the meals provided. The inspector observed part of the lunchtime meal. The meal was well presented and served in pleasant surroundings. Staff were observed to give assistance as required. Care Homes for Older People Page 14 of 25 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns and have access to a complaints procedure, are protected from abuse and have their rights protected. Evidence: The home has a policy and procedure in relation to handling complaints. This was seen to be available. One service user who spoke to the inspector confirmed they were aware of how to raise any issues. All service users who spent time with the inspector said they felt safe and comfortable and had no concerns. Information contained in the AQAA indicated the home has received three complaints in the last twelve months. The inspector was shown documentation to record any complaints received. Two of the staff who spoke to the inspector confirmed they had received training in relation to protection of vulnerable adults. Staff who spoke to the inspector were able to demonstrate through response to questions the action they would take if they became aware of a concern. All demonstrated a commitment to protecting service users from abuse. The home has a policy in relation to prevention of abuse and reporting concerns. Care Homes for Older People Page 15 of 25 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables people who use the service to live in a generally safe, and comfortable environment which encourages Independence. Evidence: During the visit the inspector walked around the building. It was seen that the home provides a clean, odour free and homely environment. Work has been carried out to refurbish and redecorate the ground floor in readiness for the new dementia care unit. Bedrooms were seen to contain new furniture. It was also seen that rooms had clear identification to promote service users Independence. Decoration included large murals to a number of walls and an area of touch and feel items. Decoration, carpets and some furnishings to a number of first floor bedrooms and communal areas were found to be old and worn. The bath in one first floor bathroom was out of order and had a badly marked seat. Another bathroom contained a shower that was positioned next to the door, reducing privacy. The first floor bedrooms, bathrooms and corridors would benefit from refurbishment to the same standard provided on the ground floor. A number of bedroom doors were seen to be wedged open. These were removed at the time of the inspection. Care Homes for Older People Page 16 of 25 Care Homes for Older People Page 17 of 25 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are satisfied with the care they receive. The home has a recruitment procedure that promotes the safety and wellbeing of service users. Evidence: On the day of inspection the home was accommodating eighteen service users on the first floor only. Five of these people were receiving nursing care. On the day of the visit the inspector found there was one qualified nurse, supplied from an agency, one senior care assistant and two care assistants on duty. Service users who spoke to the inspector told her there were sufficient staff to meet their current care needs. Those who spoke to the inspector told her they were satisfied with the care they receive. One person said the staff are good. Staff who spoke to the inspector told her there were sufficient staff to meet service users needs. The inspector was told there had been no new staff recruited for some time. However the manager was in the process of recruiting staff for the dementia unit. The manager was able to describe the process that is followed to obtain satisfactory recruitment checks prior to employment. Information in the AQAA indicated the home has a policy and procedure in relation to recruitment. The file of the qualified member of staff contained no evidence of Professional Care Homes for Older People Page 18 of 25 Evidence: Identification number (PIN) check being carried out since employment. Therefore it was not possible to check this persons continued eligibility to practice. The manager told the inspector the home has recently used agency nursing staff on a number of occasions. The inspector was not able to evidence that confirmation had been obtained for each individual confirming that satisfactory employment checks had been carried out. The inspector examined the files for one qualified nurse and three care staff. Staff files seen by the inspector contained evidence that staff have received training including moving and handling, fire safety, and prevention of abuse. Staff have also received training in dementia awareness. Staff who spoke to the inspector confirmed this. Information in the AQAA returned to CSCI indicated 9 of the care staff had successfully completed NVQ at level 2 or above and a further 3 staff were undertaking the training. Care Homes for Older People Page 19 of 25 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect, has quality assurance systems that should promote the safety and wellbeing of service users. Evidence: The manager has recently taken up the position and is to submit an application to registered with CSCI. Staff who spoke to the inspector told her communication is good, they have regular supervision and meetings. The inspector saw evidence of monthly Regulation 26 visits and reports. The manager carries out monthly audits of care plans, medication and accidents. Records seen indicated that accidents are recorded appropriately and analysis takes place. Information contained in surveys returned to CSCI indicated people were generally satisfied with the care they receive. One person stated I have never needed to Care Homes for Older People Page 20 of 25 Evidence: complain. The home operates a joint account for service users personal monies in line with the policy of Four Seasons Health Care LTD. The inspector was told the account is audited on a regular basis by financial staff employed by Four Seasons Health Care LTD. Information contained in the AQAA returned to CSCI indicated the home has a range of policies and procedures that should promote the safety and wellbeing of service users. Other information indicates the home and the majority of equipment are maintained as required. Certificates relating to the servicing of the passenger lifts seen by the inspector were dated November 2007. The manager contacted the engineers on the day of the inspection. The inspector was informed a service visit had taken place later that day. Other records seen indicate fire alarms are tested on a weekly basis. Care Homes for Older People Page 21 of 25 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 22 of 25 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 19 13 The registered person must 30/11/2008 ensure service user bedroom doors are not wedged open. Action should be taken to ensure there are sufficient door guards to allow service users the choice of leaving their door open. To promote the safety, choice and Independence of service users. 2 29 19 Evidence must be obtained 30/11/2008 that all agency staff employed by the home have had satisfactory recruitment checks carried out. To promote the safety and protection of service users. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 9 Annual competency checks should take place for all staff who administer medication to promote safe handling for the Page 23 of 25 Care Homes for Older People safety and wellbeing of service users. 2 9 Hand written entries on MAR charts should include the signature of the person making the entry and the signature of a second person confirming the accuracy of details to promote the safety and wellbeing of service users. Work should continue to develop the activities provided to ensure all service users social and recreational needs are met. Work should continue to refurbish the first floor bedrooms and communal areas to the same standard as the ground floor. Action should be taken to repair or replace the broken bath in the first floor bathroom. Regular checks of qualified nursing staff PIN should be carried out to confirm continued eligibility to practice. The manager should submit an application to register to CSCI. 3 12 4 19 5 6 7 19 29 31 Care Homes for Older People Page 24 of 25 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 25 of 25 - 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!