CARE HOMES FOR OLDER PEOPLE
Manor Way Centre Manor Way Crewe Cheshire CW2 6JS Lead Inspector
Mr Val Flannery Unannounced Inspection 09:10 1st March 2006 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 Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 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 Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Manor Way Centre Address Manor Way Crewe Cheshire CW2 6JS 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) 01270 255248 01270 250638 heathersimpson@clsgroup.org.uk www.clsgroup.org.uk CLS Care Services Limited Mrs Heather Simpson Care Home 41 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (41) of places Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A maximum of 41 service users in the OP category may be accommodated. Within that number I named service user may be (DE). When the home no longer cares for this service user registration reverts to 41 service users in the OP category 19th July 2005 Date of last inspection Brief Description of the Service: Manor Way Centre provides care for forty-one older people. Located on a residential estate in Crewe the home is within reach of local facilities such as a shop, pub and is on the bus route to the town centre. Access between the ground and first floor of the two-storey building is by a passenger lift or stairway. All the bedrooms are single and contain hand-washing facilities. There are sufficient toilets and bathrooms to meet the needs of residents. There are a variety of aids and adaptations around the building to help residents with mobility problems. Dining areas are provided on both floors; as are a number of communal lounges. Residents have access to the garden to the rear of the home as well as a veranda area on the first floor. Staff are on duty twenty-four hours a day to deliver care to residents. Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out over four hours on the 1st March 2006. One hour was spent preparing for the inspection which included reading the previous inspection report and reviewing the service history for the home. Feedback following the inspection was given to the registered manager on the 3rd March 2006. During the inspection five residents, one relative, one visitor and five staff (including the registered manager) were spoken with. Three residents’ records as well as a number of other records were seen. A partial tour of the building was carried out What the service does well:
A copy of the statement of purpose and service user guide as well as a copy of the previous inspection report is on display in the home. Also on display were copies of the National Minimum Standards and other information. Residents said staff visited them before they came to live the home and asked them about their care needs. The relative spoken with said they were able to visit the home on behalf of their relative and before making a decision about moving in. They also said they were given information about the service offered by the home. Residents said they are asked about their preferences regarding activities. They also said they are visited by doctors and other health professionals. The relative said they are able to visit the home as they wish and are made very welcome by staff. They also said they are kept informed of events that affect their relative. A well-balanced menu is offered to residents that includes choice and variety of foods. Residents said they ‘like the food’ Procedures are in place that ensures the protection of residents and enables them to raise issues of concern. Residents live in a safe and comfortable environment that is homely and offers single bedrooms and a variety of communal areas- both inside and outside the home. Staff are encouraged to develop their caring skills through training opportunities and supervision/ support from senior staff. For example, fifteen
Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 6 staff including care staff, general assistants and the maintenance assistant have a first aid qualification. Two of the care team leaders are internal assessors for NVQ. 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. Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 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 Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 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): 1/2/3/4/5 Prospective residents and their relatives are provided with information about the service offered by the home. This is made available prior to making a decision about moving in. EVIDENCE: The following information was on display in the entrance area: • A copy of the National Minimum Standards • A copy of the Care Homes Regulations • Copies of previous inspection reports • A copy of the Statement of Purpose/ Service User Guide • A copy of the Policy and Procedure on ‘Customer Feedback’. A copy of the inspection report as well as other information was seen in residents’ bedrooms. Three residents said they had read the report and the other information. The three most recent admissions to the home (including a resident on short stay) were seen. These contained pre-admission assessments carried out by
Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 9 staff from the home and copies of standard assessment documentation provided by the placing authority. Residents said their relative/other representative had visited the home on their behalf prior to moving in. A copy of the statement of the terms and conditions of residency were seen on residents files. Residents and the relative spoken with said they are satisfied that the home is providing the level of service promised. They also said they were given a copy of the statement of Purpose/Service User guide. Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 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): 7/8/9/10/11 Residents’ health and personal care needs are set out in their plans of care. Residents are treated with respect by staff who also recognise their right to privacy. EVIDENCE: Three residents’ plans of care were seen during the inspection. These showed that residents’ health, personal and social care needs have been identified; also included were details on how their needs were to be met. Residents said their health care needs were discussed with them before they moved into the home. Residents, and the relative spoken, with said they receive visits from doctors and other healthcare professions. Two residents said they were expecting a visit from a district nurse to change their dressings. Letters were seen on residents’ files that showed they are supported to attend hospital appointments at the local hospital. Residents’ files contained a range of background information and personal histories. A sample of the records of medication administered to residents by staff was seen. Staff signed these. The care team leader was also seen giving residents their medication. One resident has been assessed as able to manage her own
Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 11 medication. A locked drawer has been provided in her bedroom in which the medicine can be stored. The residents, relative and other visitor spoken with said staff are ‘very kind and caring’. Residents also said staff ‘do not rush them and ask if they are ok’. CLS Care Services have provided policies and procedures on caring for residents who are ill or dying. Copies of these are available to staff. Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 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): 12/13/14/15/ Residents are enabled to exercise control over their daily lives. This helps maintain their independence. Assessments are in place that ensure residents take responsible risks in their day-to-day living. EVIDENCE: Residents spoken with said staff help them to exercise choice over their daily lives. For example, they are able to choose when they get up and go to bed, where they spend their leisure time, whom they mix with socially and where they eat their meals. Two residents said they prefer to spend their time in their bedrooms, staff were seen bringing them their meals. One resident said she likes to be useful and was seen carrying out cleaning tasks. The relatives and visitor said they are able to visit the home as they wish. Staff, they said, make them feel very welcome and keep them informed of any incidents/accidents. They also said they are given information on maintaining contact with residents. This information is also included in the statement of purpose and service user guide. Plans of care also contained details on family background and involvement. Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 13 Residents said the food ‘is very good’ and that they are informed of what choices are available on a daily basis. The relative and visitor said the residents have commented on the quality of the food. Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 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): 16/17/18 Satisfactory arrangements are in place to respond to complaints and adult protection issues and to protect the legal rights of residents. EVIDENCE: A comment and complaints procedure is on display in the entrance area. Comment cards are available which allow residents and visitors the opportunity to raise concerns/compliments. The complaints procedure includes details on how to contact the Commission for Social Care Inspection. According to the manager the home has not received any complaints since the last inspection. CSCI has not received any complaints about the home. It is the policy of the organisation that, wherever possible, residents and/or their relatives are responsible for managing their financial and other affairs. CLS Care Services have provided an adult protection procedure, which includes the government guidelines ‘No Secrets’. The manager confirmed that they have not had any adult protection issues since the last inspection. Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 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): 19/20/21/23/24/25/26 The home provides a safe and comfortable standard of accommodation for residents. They are able to bring personal possessions with them when they come to live in the home. EVIDENCE: The home is well maintained and provides a safe and comfortable environment for residents. A garden to the rear of the home is accessible to residents and provides a safe and pleasant outdoor area. The balcony area, located off a lounge on the first floor, provides an outdoor area for residents whose bedrooms are on the first floor. Toilet and bathing facilities are provide as follows: Ground floor • Seven toilets • Three toilets/bathrooms • One shower
Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 16 • • First • • • • • Two lounges One lounge/dining area Floor Three toilets One toilet/shower One toilet/bathroom One dining area One lounge Toilet and bathing facilities are close to residents’ bedrooms and communal areas. Residents are accommodated in single bedrooms. The rooms seen contained residents personal possessions. Residents said they are ‘happy with their rooms and prefer single rooms’. Three said they ‘are sure they could have a key if they wanted one’. On the day of the inspection the home was clean and free from unpleasant odours. Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27/28/30 The number, and experience, of the staff, meet residents’ care needs. Staff receive training and support in order to carry out their duties. EVIDENCE: The staffing rota showed that there was one care team leader and three care assistants on duty during the morning/afternoon/evening. There is normally one care team leader and one care assistant on waking duty during the night. There was also a care team leader on duty who was up dating residents’ care plans and other records. Three general assistants, one cook and a maintenance assistant were also on duty. A home service manager is responsible for managing support staff and the home’s administration procedures. Residents’ spoken with said staff are ‘hard working and look after them well’. One resident said they’ could do with more staff in the home’. Residents also said ‘they like living in the home as their relatives live close by’. During the inspection staff were observed helping residents with a range of tasks such as using the bathroom, dressing, eating and moving between their bedrooms and communal areas. This was done in a manner which maintained residents’ dignity and self-respect. Staff spoken with said they attend training courses such as first aid, fire safety and manual handling. On the day of the inspection the manager was providing refresher training on manual handling for staff, this was being carried out in
Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 18 another CLS home. The manager confirmed that they were working to achieve 50 of care staff NVQ trained by the end of the year. She also said that there are fifteen staff with a first aid qualification currently working in the home. Two staff were also NVQ assessors. Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 19 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): 31/32/33/36/37/38 The registered manager has the experience and the qualifications to ensure the home is run in the best interests of residents. EVIDENCE: The manager has been employed by the organisation in a senior capacity for a number of years. She has completed her NVQ Level 4 in management and Registered Managers Award. She has attended training required for the day-today running of the home included a weeklong course on caring for residents with dementia. During the inspection the results of residents/relatives’ satisfaction survey were seen. The majority of residents and relatives said they are satisfied with overall service offered. Residents and the relative spoken with during the inspection confirmed that they feel the home has improved and that the manager listens to their concerns and acts upon them. Staff spoken with said
Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 20 they are supported, and receive individual supervision, from senior staffing the home. CLS have provided a range of policies and procedures, copies of which are available to staff and others. A number of health and safety records were seen; these were satisfactory. Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 21 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 4 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 X X 3 3 3 Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Manor Way Centre DS0000006506.V281828.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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