Inspection on 15/11/05 for Manor Park Care Home

This inspection was carried out on 15th November 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.

Other inspections for this house

Manor Park Care Home 26/04/07

Manor Park Care Home 13/06/06

Manor Park Care Home 04/05/05

Manor Park Care Home 03/11/04

Manor Park Care Home 02/09/04

Manor Park Care Home 31/03/04

Manor Park Care Home 21/01/04

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

CARE HOMES FOR OLDER PEOPLE Manor Park Care Home 3 Ellenborough Park North Weston Super Mare North Somerset BS23 1XH Lead Inspector Juanita Glass Announced Inspection 15th November 2005 09:00 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 Care Home DS0000043913.V254082.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 Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manor Park Care Home Address 3 Ellenborough Park North Weston Super Mare North Somerset BS23 1XH 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) 01934 635432 01934 641045 enquiries@manorparkcare.co.uk Manor Park Care Ltd To be appointed Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate one person aged 59 years and over. This condition applies to a named individual and will no longer apply if this person leaves the home. For 38 service users, the minimum staff on duty will be 2 care staff in each unit and a 5th person covering both the units (the 5th person can include the home manager), three care staff on duty at night. May accommodate up to 5 service users, aged 60 years and over, who have dementia. That occupancy remains at 35 until notice of completion is received for the remainder of the building and the Inspector is satisfied with provision in place. That any day care provided does not impact on the National Minimum Standards for the service users resident in Manor Park. 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Manor Park Care Home is registered with the Commission for Social Care Inspection to provide non-nursing care for 38 service users aged 65 and over with Dementia or associated conditions. It is approximately 500 yards from the sea and within close proximity of shops and local amenities. Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There was a very pleasant relaxed atmosphere during this inspection now most of the building work has been completed; all of the residents were observed used in all parts of the home and enjoying the new communal areas. One bedroom was still being decorated and fitted out during the inspection this bedroom can be occupied once the commission has been informed of its completion and has been inspected and passed as fit. The acting manager was present through out the inspection. Two Comment cards had been received from relatives both appeared satisfied with the care provided however that felt that they could be to informed of important matters affecting their relative/friend. And one in comments mentioned the need for relative meetings. Residents spoken to during the inspection expressed satisfaction with the care they received, however most of the residents were unable to express an opinion do you do their level of understanding. Residents were observed to be relaxed and happy, and have an easy and friendly rapport with staff. Six requirements were made during this inspection and no requirements were outstanding from the last inspection. The inspector also discussed with the manager the need for the adult protection policy to show a flow chart of action to be followed if an accusation was made, and the need for clear risk assessments for under 18’s work placements from Weston College. What the service does well: What has improved since the last inspection? Two requirements made at the last inspection have been met. Planned staff supervision has commenced and all staff have attended fire drills in line with current guidelines. The building programme is largely finished and this was evident in the relaxed and quiet atmosphere in the home. Manor Park Care Home DS0000043913.V254082.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 Care Home DS0000043913.V254082.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 Care Home DS0000043913.V254082.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): 1, 3, 4 and 5, 6 does not apply The home provides adequate information for service users or relatives to make an informed choice. Resident needs are thoroughly assessed before admission to Manor Park Care Home. Service users and relatives/friends are offered an opportunity to visit the home. EVIDENCE: The Statement of Purpose and Service User Guide and have not been reviewed since the last inspection, and they contain all the information needed to make an informed choice about staying at home. However it was noted that they had not been updated to reflect the increased numbers of beds in the home. It was recommended that both the Statement of Purpose and Service User Guide needs to be reviewed and the up to date copy be available on request. The acting manager confirmed that she visits prospective residents and carries out a thorough preadmission assessment before offering them a place at Manor Park, records reviewed contained signed but undated preadmission assessments carried out by the manager, it was recommended that all preadmission assessments need to be dated, the records were holistic Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 9 including input from social services or hospital. The manager encourages prospective residents all family members, relatives or advocates to visit the home prior to arranging admission, a relative or representative usually takes this up. Residents spoken to were unable to express an opinion on the admission process. Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 10 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 and 10 The health and personal care needs of residents are well met. There is a friendly atmosphere in the home with evidence of a good rapport between residents and staff. Residents are protected by the homes policies and procedures for storage and administration of medication. EVIDENCE: Care plans reviewed showed that individual identified needs were considered, they all contains comprehensive assessments were very clear guidance staff. Specific risk assessments for falls and aggressive behaviour were in place and showed evidence of regular review. All the care plans seen had been reviewed on a regular basis and showed evidence of resident or relative involvement. The manager confirmed that they had adequate support from the GP and the district nurse; they also have a very good relationship with the mental health team at Weston General Hospital. Few of the residents were able to initiate a conversation but were happy to talk to the Inspector when approached, they were well groomed neat and tidy and all the gentlemen were clean-shaven. Residents were observed to be relaxed and generally happy in the presence of staff. Records showed that residents Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 11 have been assisted to attend outpatient appointments, the dentist, the opticians and had regular attendance from a chiropodist. The homes policies and procedures for the ordering storage and Administration of medication are very clear and concise; all staff administering medication have received appropriate training and are aware of the policies and procedures in place. An audit trail showed no errors, medication was stalled and recorded appropriately. Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 12 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 and 15 The home provides a range of meaningful activities, which are very popular. Visitors are actively welcomed into the home. The routines of daily living a sufficiently flexible to give residents an element of tourists. Residents receive a whole some appealing well-balanced diet. EVIDENCE: The home is currently on a pilot scheme for the PAL (planned activity level) they are currently carrying out the assessments with residents and planning to put the activities into action. There is a programme of activities placed on a two weekly rota and these include News reviews, discussion groups and outings. The activities diary maintained by the home showed that residents had taken part in exercising to music, music and movement, pet therapy, music, cinema visits with the Alzheimers Society, painting, word games and board games. Residents were unable to comment on the level of activities in the home however during the inspection it was noted that care staff were making an obvious effort to interest residents in different activities. One care assistant was reading a pictorial yearbook with one resident, whilst another was playing the piano. In the afternoon most of the residents enjoyed a visiting musician, and were observed happily dancing to the music. The home actively encourages visitors into the home and there are no restrictions. Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 13 During the inspection residents were observed making personal choices as to where they sat what they had for lunch and one gentleman was offered a trip in the minibus and chose to go out. The home as a four week menu, which provides residents with the choice of meals that they would recall as being popular meals from their younger days. Residents spoken to said that theyd had a lovely lunch and at the meals were a always very good. One resident was noted to be very eager to get into the dining room for lunch and said she always enjoyed her meals here. Special dietary arrangements can be made for either personal preferences or medical needs. The cook stated that she was always informed of any dietary requirements or special preferences. Staff are available to assist residents were necessary and this was observed to be unobtrusive and unhurried. Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 14 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 and 18 The complaints procedure in the home is satisfactorily and staff demonstrated a good awareness of adult protection issues. EVIDENCE: The homes policies and procedures for complaints, adult protection and whistle blowing are all in place and contained very clear guidelines. However in discussion with the manager it was recommended that the adult detection procedure should include a flow chart showing what action should be taken if an accusation of abuse was made. The home keeps a record of all complaints made these include the action taken and an eventual outcome. No complaints have been received since last inspection. A copy of the North Somerset inter agency policy and procedure for adult protection is kept in the office for staff to refer to, staff spoken to demonstrated a clear awareness of the issues surrounding the protection of vulnerable adults and the manager is accessing training provided by North Somerset social services. Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 15 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, 20, 25 and 26 Manor Park provides comfortable and homely accommodation, which is clean and tidy and well furnished. EVIDENCE: A tour of the premises was carried out during his inspection as all the new areas were now open for use by residents. All rooms were appropriately furnished in a homely and domestic manner. Residents were observed to be using all the communal areas. The home has a level access and a lift to all floors. The standard of housekeeping was particularly good the home was clean and tidy and free from offensive odours staff of all attend training in infection control and they all carry small bottles of hand disinfectants. Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 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, 29 and 30 The numbers of staff on duty are sufficient to meet the needs of the current resident group. Recruitment procedures failed to meet the standard required. Staff receive training which equips them to work in a dementia care setting EVIDENCE: Duty rotas for four weeks prior to inspection showed that staffing levels have been increased to meet the growing number of residents in the home, the staffing levels were adequate for the number of residents and their range of needs. Staff spoken to confirmed that adequate staffing levels are maintained, residents were unable to comment on the number of staff on duty, however one lady said ‘theyre always here for us.’ Staff records reviewed showed that the home continues to have a problem acquiring the POVA first check. Staff had been employed without the home obtaining a POVA first check, a requirement was made to address this shortfall. The home continues to use the distance learning provided by red crier, and all staff have received mandatory training in health and safety, fire protection, manual handling and food hygiene. Courses available to staff are advertised on the noticeboard and it was noted that dates had been found for adult protection training run by North Somerset social services. Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 17 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, 32, 35, 36, 37 and 38 The manager needs to complete the registration process. The staff group work well together to meet the aims of the home. The implementation of health and safety is not adequate and does not meet current requirements. EVIDENCE: The acting manager is a registered nurse with experience in dementia care she is also an appointed first data and manual handling instructor she has commenced a registered managers Ward and yet has yet to complete the registration application with CSC by. Staff spoken to felt they could talk with the manager and the comments raised would be considered and acted on, resident spoken to were unable to express an opinion however interactions observed showed that they got on well on that there was a good rapport. One member of staff commented on the acting manager working alongside staff and felt that this helps maintain staff morale. Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 18 An audit of balance sheets for two residents ‘pocket money’ accounts was carried out and no mistakes were seen, the home prefers relatives to deal with resident’s money and discourage large amounts of money in the home. Joe is outfalls supervision for staff in line with the current requirement however it was noted that the manager does not receive any formal supervision, a requirement was made that the registered provider must carry out formal supervision of the manager at least six times a year. All policies and procedures in the home were advised and up-to-date they were available for inspection. However the recording of accidents was being made on inappropriate forms, this was discussed with the manager. The CSCI also has not received a monthly report from the registered provider under regulation 26. The implementation of health and safety in the home was largely satisfactory with the exception of the fire log, which showed that the home was not carrying out some checks on the fire equipment and emergency lightning in line with current guidelines. It was also noted that there were no generic risk assessments for the home all for working practices that posed a risk to staff or residents. Since the last inspection all staff have attended a fire drill in the home. Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 19 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 3 3 3 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 x 18 3 3 3 x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 x x 3 2 3 2 Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 20 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 2 3 4 5 6 Standard OP29 OP36 OP37 OP38 OP38 OP38 Regulation 19 (1) 18 (2) 26 Sch 4 (12a) 12 (1) 13 (4) 23 (4) Requirement The home must obtain a POVA first confirmation before employing new staff. The manager must receive formal supervision at least 6 times a year. The registered provider must forward a monthly report to the CSCI All accidents must be recorded on the appropriate forms The manager must carry out a generic risk assessment of the home and working practices. Fie fighting equipment and emergency lighting must be checked in line with current guidelines Timescale for action 16/11/05 16/11/05 16/11/05 16/11/05 16/01/06 16/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 21 1 2 OP1 OP38 The statement of purpose needs to be reviewed to reflect the increased numbers in the home. Clear risk assessments need to be in place if under 18’s carry out work placement in the home. Manor Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Park Care Home DS0000043913.V254082.R01.S.doc Version 5.0 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. 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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