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Inspection on 04/04/07 for Manor Road, 2

Also see our care home review for Manor Road, 2 for more information

This inspection was carried out on 4th April 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents, where able, described good relationships with the staff and said they were all polite and helpful. Staff were friendly and relaxed and showed a good understanding of service users needs. Arrangements for service users to maintain contact with their family and friends are good. Service users said their visitors are always made welcome and kept informed and involved. A variety of social activities were available providing residents with varied and interesting days. Meals are varied, well balanced and nicely presented offering good choice and nutritious food at all meals. All of the residents spoken to were pleased with the quality and choice available. Meals are viewed as a relaxed and social occasion. Hygiene practices were good protecting the health of service users and staff. The home is well staffed with a skilled, consistent and trained staff team giving security to residents. Staff recruitment and training records were clear and concise and contained all relevant information. The vetting process helps protect residents. Although not fully documented, the staff has a good understanding of residents individual needs. More than 75 percent of staff is qualified to National Vocational Qualification in Care level 2 (NVQ) or above providing residents with a trained, skilled staff team. The residents were very complimentary about the staff.

What has improved since the last inspection?

Since the last inspection visit, several bedrooms, corridors, and other communal areas of the home have been redecorated. Several service users commented on these very positive improvements. Staff training and development has continued to progress well, and includes equality and diversity training. The training officer monitors all staff training to ensure it meets National Training Organisation workforce training targets.

What the care home could do better:

The service users care records and risk assessments need to be improved, these should identify the holistic needs of each individual, and the action which needs to be taken by care staff to ensure that all aspects of their health, personal and social care needs are met. Risk assessments do not fully describe the identified risks, or how these will be managed. The format used does not provide enough space to record information accurately, potentially placing service users at further risk.

CARE HOMES FOR OLDER PEOPLE Manor Road, 2 2 Manor Road Tynemouth North Shields Tyne & Wear NE30 4RH Lead Inspector Jim Lamb Key Unannounced Inspection 4th April 2007 09:30 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 Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 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 Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Road, 2 Address 2 Manor Road Tynemouth North Shields Tyne & Wear NE30 4RH 0191 2574519 F/P 0191 2574519 No Email 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) Kay Care Services Limited Mrs Susan Anthea Baston Care Home 24 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (19) of places Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: The home provides personal care and accommodation for older people who require long-term care. The home is located in the village of Tynemouth close to shops, pubs, the post office and seafront. There are good transport links near-by. The home has a passenger lift, and service users have access to a landscaped front garden and a paved courtyard. Fees for the home are £385.00 per week. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection visit. The inspection took place during the morning and early afternoon. Time was spent talking the manager, one staff and twelve service users. Service users care records were inspected together with other records relating to the management of the service. A tour of the premises also took place. Fourteen service users feedback cards were received; all indicated that they were happy with all aspects of the care that they receive. What the service does well: Residents, where able, described good relationships with the staff and said they were all polite and helpful. Staff were friendly and relaxed and showed a good understanding of service users needs. Arrangements for service users to maintain contact with their family and friends are good. Service users said their visitors are always made welcome and kept informed and involved. A variety of social activities were available providing residents with varied and interesting days. Meals are varied, well balanced and nicely presented offering good choice and nutritious food at all meals. All of the residents spoken to were pleased with the quality and choice available. Meals are viewed as a relaxed and social occasion. Hygiene practices were good protecting the health of service users and staff. The home is well staffed with a skilled, consistent and trained staff team giving security to residents. Staff recruitment and training records were clear and concise and contained all relevant information. The vetting process helps protect residents. Although not fully documented, the staff has a good understanding of residents individual needs. More than 75 percent of staff is qualified to National Vocational Qualification in Care level 2 (NVQ) or above providing residents with a trained, skilled staff team. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 6 The residents were very complimentary about the staff. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 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 Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users are appropriately assessed prior to admission into the home, and are provided with enough information about the home prior to admission. All are provided with a written contract explaining their terms and conditions with the home. EVIDENCE: Details of the extra charges, and what these are for, are in the contract given to service users and are agreed prior to their admission. The home’s Statement of Purpose needs a slight amendment to inform prospective service users of the current managers details. Two service users’ files were checked and each included a full up to date needs assessment. They contained a range of appropriate information. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 9 The service users are involved in drawing up these initial assessments. For those self-funding and without a Care Managers assessment, a skilled member of staff always undertakes the assessment. The assessment also involves the family or a representative of the service user. The service users said their needs were met and they were happy with the care offered to them. One service user said “This is home is similar to a very good hotel, and the staff are very caring”. Staff interviewed had had a range of relevant training and experience. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning system is not clear enough to ensure that staff have the information they need to meet the assessed needs of the service users. The risk assessments do not protect service users; they do not describe fully identified risks or how these will be managed. EVIDENCE: The risk assessments were not comprehensive, they did not take into account fully each individual’s needs and aspirations for independence and choice, or describe how to minimise each risk identified. The risk assessment format should be revised to provide enough space to record information accurately. There are advocacy arrangements, as well as family input to represent service users. Each service user has an allocated key worker. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 11 Staff were observed communicating with service users in a kind, considerate and helpful manner. Service users spoken to confirmed that staff respects their privacy and treated them in a dignified manner. Care plans are drawn up with service users. Plans are not fully amended and reviewed on a regular basis. The care plan should be a working tool that is understood by service users, by staff, and service users’ representatives. The plans should describe service users holistic needs, and strive to promote their independence. The manager said that she would put systems in place to ensure the plans are up-dated and reviewed. The service arranges additional reviews when changes take place. The staff spends time with service users to communicate their views for the on-going development of the annual review process. Service users, care managers and their representatives attend annual reviews. Self-advocacy is promoted and service users can access a range of external agencies that promote independence. Any rights that are restricted should be linked to risk assessments. The health care needs of service users are appropriately met. The medications systems for ordering, administration and disposal are well managed. Several service users are supported to manage their own medications, and they have a lockable drawer in their bedroom for safe storage of these. All staff has undertaken accredited medication training. Service users all indicated that they are able to make decisions for themselves. One service user said, “I am able to come and go as I please. Mrs Baston and the staff are great people, they help me to remain physically fit”. Another said, “I am aware that there are records kept about me, and staff do ask me about becoming involved in these, but I am not really interested. I am happy living here, the staff team are very good”. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The meals in the home are good, offering both choice and variety. The service users have opportunities for personal development and leisure activities. They are supported to maintain very good links with the community and their relatives and friends. EVIDENCE: Each service user had practical health and personal skills assessment carried out. All service users participate in this process. Service users are supported to live a normal life in the community. They are supported and encouraged to be in control of their own lives, and enjoy their own interests and hobbies. For a small fee, some service users have opted to have a community support worker allocated to them. This supports them to enjoy a more stimulating lifestyle with a choice of options to choose from. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 13 Two service users said that they are supported to attend church each week, and others said, there are regular religious services held in the home. All service users are supported to maintain very close links with their families. They can choose who they want to see and when. Several service users have a private telephone in their bedrooms; this enables them to keep in regular contact with their family and friends. The service users said that they enjoy weekly visits from pupils of a local school; they assist with activities, and have been helping service users to make high quality Easter cards. Daily routines promote independence, choice and freedom of movement. The menus are based on the known likes and dislikes of the service users. At least two hot meals are provided each day. The meals are varied and well balanced. The service users said that the meals were good. Special diets are provided as and when needed, and nutritional assessments are carried out. The kitchen was found to be clean and well organised; all appropriate checks are carried out to monitor food and fridge/freezer temperatures. Good stock levels were observed. The cook always consults service users prior to any menu changes, and service users confirmed this. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good, clear, user-friendly complaints system and service user’s views are listened to and acted upon. Procedures are in place to protect service users from harm, and these are followed. EVIDENCE: There is a complaints procedure. The procedure is written in a way that ensures service users fully understand its contents. All complaints are investigated within 28 days. Since the last inspection visit, there has been one complaint received, this was fully investigated by the local Adult protection Team, the complaint was not up-held. Service users said that they had been given copies of the procedure and that staff listened to their complaints and dealt with them fairly. There is an appropriate complaints recording system in place. The service users spoken to said, they fully understood the complaints procedures, and would not hesitate to make a complaint if they needed to. The service has a Whistle Blowing policy and a copy of the Local Authorities Vulnerable Adults procedures. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 15 Training of staff in the area of protection is regularly arranged. The service ensures, through training, supervision, review and quality monitoring, which care staff fully complies with policy and procedures in relation to protecting and safeguarding the rights of the service users. The service also has a copy of the Department of Health’s document, “NO SECRETS”. The service keeps detailed financial records on behalf of the service users. Service users are encouraged to take responsibility for their own financial affairs and to use their money as they wish. Staff will support those who need help in financial matters. They work to a clear robust policy that protects service users from financial abuse. Receipts of personal spending are kept. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a very comfortable and safe environment for those living there. The standard and decoration within the home is very good. Communal areas and bedrooms are large, and meet the service users needs. All areas within the home are well maintained, clean, tidy and free from offensive odours. EVIDENCE: The home was clean, well decorated and maintained, and the grounds were tidy, safe, and accessible, with seating areas for service users. Service users can see visitors in private in their own rooms. All bedrooms have privacy locks. There are also two small visitors lounges. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 17 Furnishings and fittings were domestic in design and in good condition. Room sizes all meet the minimum required. The service users spoken to said that they were happy with the space available. The bedrooms are nicely decorated, and personalised. Seventeen of the twenty-three rooms have en-suite facilities. All bedrooms have opening windows. The rooms were centrally heated and the heating level could be controlled within each bedroom. The home is well lit, clean and tidy and smells fresh. The kitchen was found to be clean and well organised and stock levels were good. Appropriate checks are carried out including food and fridge temperatures. Water is stored at over 60°C. Valves at water outlets ensure water is provided close to 43°C to prevent scalding. The laundry facilities are well organised, and the washing machine has a disinfection control cycle. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good match of well-qualified staff offering consistency of care within the home. There are robust procedures in place for the recruitment and selection of new staff, which helps to protect service users. The staff receives supervision and this provides them with a good understanding of the service users support needs. EVIDENCE: Samples of 4 weeks’ rotas showed the required numbers of staff were on duty: In addition to the manager, there are three staff between 8am and 9pm with two between 9pm and 8am. All the staff were over 18 years of age and those left in charge were at least 21. Training needs of staff are identified in supervision and appraisal sessions. The training programme meets The National Training Organisation requirements for the first six months. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 19 All staff receive paid training. The management prioritise training and facilitate staff to undertake external qualifications beyond the basic requirements. Currently 75 of the staff team have achieved NVQ level 2/3. The service continues to operate a rigorous staff recruitment and selection process to ensure that all appropriate checks and references are in place prior to employment. The most recent member of staff employed confirmed that all of these checks were carried out prior to her employment. The service sees induction and any probationary period as being an extension of recruitment. There is little use of agency or temporary staff, and staff turnover remains low. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is supported by the organisation in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The systems for service users’ consultation are good, and service user’s views are both sought and acted upon. The health and safety of the service users is promoted. The service is aware of equality and diversity and its implications. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager has the required experience, and is competent to run the home and meet its stated aims and objectives. She has almost completed the Registered Manager Award and NVQ level 4. The staff member interviewed was clear about her responsibilities. She had a very good knowledge of the service users assessed needs. Staff and service users spoke positively about the manager saying, there is a strong ethos of being open and transparent in all areas of running the home. Service users are told when inspections take place and they are shown inspection reports. These are also summarised and discussed in service user meetings. Copies are available for relatives and others to see. The service has sound policies and procedures, which the manager effectively reviews and updates, in line with current thinking and practice. Systems are in place to monitor staff adherence to policies and procedures. The service is aware of equality and diversity and its implications, and strives to promote the diversity agenda within the service. A new policy has recently been implemented, and staff training has commenced. The service continues to operate a good quality assurance system. Service users’ views are sought and acted upon. Relatives are also consulted. The home continues to maintain a comprehensive annual development plan. The manager will also make arrangements for professional views to be sought as part of the quality assurance system. The service has a good record of meeting relevant health and safety requirements and legislation. The records inspected were found to be appropriately completed. These included the fire log book, accident records, personal allowance records and Health and Safety checklists. There are appropriate maintenance contracts for the home in place, and water storage tanks, gas and electrics are checked annually. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 22 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 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 3 3 4 4 3 4 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 3 3 3 X 3 X X 3 Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 23 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. Standard OP7 Regulation 15. Requirement Develop service users care plans and risk assessments, to ensure that service users holistic care and risk needs are clearly recorded. Timescale for action 01/07/07 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 OP7 Good Practice Recommendations Consider using a different risk assessment format for recording service users identified risks. Manor Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 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 © 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 Road, 2 DS0000000354.V330119.R01.S.doc Version 5.2 Page 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!