CARE HOMES FOR OLDER PEOPLE
Manor Park Care Home 3 Ellenborough Park North Weston Super Mare North Somerset BS23 1XH Lead Inspector
Juanita Glass Unannounced 4 May 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 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 D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Manor Park Care Home Address 3 Ellenborough Park North Weston Super Mare North Somerset BS23 1XH 01934 635432 01934 641045 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) Manor Park Care Ltd Personal Care Home Only 30 Category(ies) of Dementia over 65 years of age - (30) registration, with number of places Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. for 30 Service Users, the minimum staff on duty will be 2 care staff in each unit and a 5th person covering both units (the 5th person can include the home manager), three care staff on duty at night 2. May accommodate one person aged 59 years and over. This condition applies to a named idividually and will not apply when he leaves the home. Date of last inspection 3 November 2004 Brief Description of the Service: Manor Park Care Home is registered with the Commission for Social Care Inspection to provide non-nursing care for 30 service users aged 65 and over with dementia or associated conditions. It is approximately 500 yards from the sea and within close proximity are shops and local amenities. Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place over 7 hours, in the presence of the manager Sally Walker, the home was clean and tidy and the residents were well groomed and had a very good rapport with all the staff. The home is currently undergoing extension and refurbishment, the building works have meant that some of the communal space shared by the residents has had to be reduced however this does not appear to have had an adverse effect on the residents in the home. Those residents spoken to who could express an opinion said they were happy and that staff were ‘good and respectful.’ During this inspection six sets of care records were reviewed and the staff personnel files, however the emphasis was on the outcomes from the residents, time was spent talking to residents and observing them taking part in activities. A tour of the new extension was also carried out with a view to assessing whether rooms were ready to use in the near future. What the service does well: What has improved since the last inspection? Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 6 Since the last inspection it was noted that staff are now taking an active role in their training programme. Following a complaint that raised issues around induction all new staff now receive a thorough induction and work supervised, until considered competent to work alone. The secretary who also organises the activities programme has put a lot of hard work into providing meaningful activities that the residents enjoy, this includes an arts and crafts group, which is very popular. The planned building works have provided a range of new bedrooms with ensuite facilities and a walk-through lounge area with access to a level, secure garden. 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 D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3 and 5. Residents needs are a thoroughly assessed before admission to Manor Park Care Home, family members are provided with adequate information to make an informed choice. EVIDENCE: Mrs Walker confirmed that she visits prospective residents and carries out a thorough assessment before offering them a place at Manor Park, records seen contained dated and signed pre-admission assessments carried out by the manager the records appeared to be holistic and included input from social services or the hospital. Family members, relatives or advocates are encouraged to visit the home with or on behalf of the prospective resident, before making a final decision. Residents spoken to were unable to express and opinion on the admission process. All records examined contained very clear statements of terms and conditions, which included the service users rights and responsibilities, and a tariff of any extra charges not covered by the fee. The statement of purpose and service user guide had been updated to include the new office address for their CSCI inspector.
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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 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. EVIDENCE: Care plans showed that individual identified needs were considered, they all contained comprehensive assessments with very clear guidance for 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. 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. Records seen showed that staff were aware of individual needs and residents have been assisted to attend outpatients appointments, the dentist, the opticians and had regular attendance from a chiropodist.
Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 10 The medication administration records were well maintained, and drugs were securely stored, it was recommended that eye drops needed to be dated when they were opened. Following issues raised in a complaint forwarded to the CSCI all staff have received training in the handling and administration of medication, they have then been observed administering medication by the manager before considered competent. Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12, 13 and 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 are sufficiently flexible to give residents an element of choice. EVIDENCE: The homes Secretary also acts as the activities organiser the programme of activities is on a two weekly rota, and includes News reviews discussion groups and outings; one resident spoken to especially enjoyed the quizzes; some residents are also able to attend the Alzheimers Society tea dances. Outside entertainment is booked regularly and includes musical sessions and visiting pets. The recent introduction of an Arts and Craft group has proved very popular and residents have taken part in sessions that have included glass painting, flower arranging, plasticine moulding, basket making and card making. Residents were observed enjoying flower arranging, when spoken to they said they always enjoyed an activity that gave them something they could see at the end. Visitors were observed to be coming and going through out the day although none chose to talk to the inspector. The home has a four-week menu, which provides residents with a choice of meals that they would recall as being popular meals from their younger days. Residents spoken to said theyd had a lovely lunch and that the meals are always very good. Special dietary arrangements can be made for either
Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 12 personal preferences or medical needs. Staff are available to assist residents when necessary this was observed to be unobtrusive and the mealtime was unhurried. Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 and 18. The complaints procedure in the home is satisfactory and staff demonstrated a good awareness of adult protection issues. EVIDENCE: The complaints policy and procedure has been updated and now directs the complainants to the new address for the CSCI. Following the requirement made at the last inspection all complaints are now recorded and include action taken and outcome. Two complaints made directly to the CSCI were investigated one by the home and one by the CSCI inspector, both complaints were partially substantiated and are mentioned in the relevant parts of this report. The complaint investigated by the home was fully documented and a copy was sent to the CSCI. Following the requirement made at the last inspection the homes policy and procedure for the protection of vulnerable adults has been replaced in the policies file and is available for staff. Both this policy and the homes whistle blowing policy are very clear, staff spoken to demonstrated a good awareness of the issues surrounding the protection of vulnerable adults. Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 20, 23, 25 and 26. Manor Park offers comfortable and homely accommodation, which is clean tidy and well furnished EVIDENCE: A complete tour of the premises was not carried out during this inspection, however the new build areas were inspected with a view to opening rooms to residents. It was felt at this time that the rooms were not ready for accommodation and another date was arranged; when it was anticipated that the new en-suite bedrooms and lounge area would be completed. The new lounge will have access to a level courtyard area with raised flowerbeds. The home has a level access and a lift to all floors and residents were observed to be using all the communal areas available. Furnishings and lighting are domestic in style and there was sufficient lighting in the communal areas to read by. The standard of housekeeping was particularly good. The homes clean tidy and free from offensive odours staff have attended training in infection control and it was observed that all staff now carry small bottles of
Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 15 hand disinfectant, which are attached to their uniform pockets staff spoken to showed an awareness of the importance of infection control. Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 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 induction and training to equip them to work in the dementia care setting. EVIDENCE: Duty rotas for the four weeks prior to inspection showed that staffing levels were adequate to the number of residents and the range of needs. Staff spoken to confirmed the adequate staffing levels are maintained, residents were unable to comment on number of staff on duty. Any shortfall in staffing numbers is made up by agency staff. Staff records reviewed showed that the home continues to have a problem acquiring the POVA first check, this was discussed with the manager and it was suggested that they tackle this problem directly with the umbrella company who provides CRB checks. The home continues to use the distance learning provided by Red Crier, staff are in the process of receiving mandatory training in health and safety, fire protection, manual handling and food hygiene, dates of the next course were advertised on the notice board. Following issues raised by a complaint forwarded to the CSCI all staff now received a full induction and work supervised until considered competent. Staff spoken to said that they felt adequately supported with training. Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36, 37 and 38 The staff group work well together to meet the aims of the home. Shortfalls in health and safety could be improved by the introduction of regular fire drills. EVIDENCE: The manager Sally Walker is a registered nurse with experience in dementia care also an appointed first aider and manual handling instructor she has commenced the registered managers award and has yet to complete the registration application with CSCI. Staff spoken to felt they could talk with the manager and the comments raised would be considered and acted on, residents spoken to were unable to express an opinion however interactions observed showed that they got on well and that there was a good rapport. The manager stated that she had started supervision with staff however it was not on going and had not progressed any further. All the required documentation was available for inspection, and health and safety within the home was satisfactory it was however noted that not all staff had attended a
Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 18 full fire drill within the home, specific emphasis during discussion with the manager was placed on the need for night staff to attend fire drills in line with Avon and Somerset Fire Brigade guidelines. Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x 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 x 15 3
COMPLAINTS AND PROTECTION 3 3 x x 3 x 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x 2 3 2 Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 36 38 Regulation 18(2) 12(1) Requirement All staff must formal supervison at least 6 times a year All staff must attend fire drills in line with the Avon and Somerset firebrigade guidelines Timescale for action From 04/05/05 From 04/05/05 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. Refer to Standard 9 Good Practice Recommendations Eyedrops need to be dated on opening. Manor Park Care Home D53 -D02 S43913 Manor Park V222301 04.05.05 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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