Inspection on 18/01/07 for Manorcroft Nursing Home

This inspection was carried out on 18th January 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.

Other inspections for this house

Manorcroft Nursing Home 28/11/05

Manorcroft Nursing Home 22/08/05

Manorcroft Nursing Home 09/03/05

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Manor Croft Nursing Home Old Bank Road Dewsbury West Yorkshire WF12 7AH Lead Inspector Karen Summers Key Unannounced Inspection 09:00 18 & 19th January 2007 th 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 Croft Nursing Home DS0000001090.V322081.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 Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Croft Nursing Home Address Old Bank Road Dewsbury West Yorkshire WF12 7AH 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) 01924 467521 01924 488036 manor.croft@tri-care.co.uk Tri-Care Limited Mrs Juliet Robbins Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Terminally ill over 65 years of age (2) of places Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2005 Brief Description of the Service: Manor Croft is a purpose building nursing home providing nursing care for up to 40 older people. Orchard Care Homes Ltd owns the home. The accommodation is on two floors, the first floor being accessed by a passenger lift. All bedrooms have en-suite facilities. The home is situated close to Dewsbury town centre and there is a bus stop and local shops within walking distance of the home. There is ample parking space to the front of the building. There are enclosed garden and patio areas within the grounds to enable residents to sit out in warmer weather. Information provided by the home indicated that the fees range from £385.84 to £650 per week. Additional charges are made for, hairdressing, chiropody, toiletries, newspapers, dry cleaning, and taxi’s. The service provider ensures that information about the service is available to prospective residents and the current residents by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a key inspection, which included an unannounced site visit on the 18th and 19th January 2007, and the duration of the inspection was 10 hours. There were 37 service users living at the home at the time of the inspection. Mrs Lorraine Brown, Registered Nurse, was present throughout the inspection, and Mrs Juliet Robbins the manager, was present for part of the inspection. The following areas were looked at and have been used in the production of this report; a sample of records, care plans, medication, individual discussion with service users, a chiropodist, a district nurse, two members of staff, tour of the premises and document reading. To reflect the views of those who use the service, satisfaction questionnaires were sent to: 9 service users, 7 were returned; 9-relatives/ advocate/ friends, 7 were returned, and 6 GP’s, 4 were returned. In writing this report, information and evidence was not only obtained by way of visiting the home, but also from notifications of events sent by the company to the Commission for Social Care Inspection. The last inspection report was also consulted. The inspector would like to thank those who contributed to the inspection process, and also thank Mrs J Robbins, Mrs Brown, the staff and service users, for their time and hospitality on the day of inspection. What the service does well: What has improved since the last inspection? Residents are now made aware of the meal available each day, and have an opportunity to choose an alternative if they wish. A number of areas have been redecorated throughout the home, and the lounge and staircase carpets have been replaced. Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Manor Croft Nursing Home DS0000001090.V322081.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 Croft Nursing Home DS0000001090.V322081.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): 2,3 & 5. 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No service user moves into the home without having had his/ her needs assessed. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. EVIDENCE: Prospective service users are encouraged to have a look around the home before deciding to live there however, the majority of people moving in are quite ill and so relatives visit on their behalf. Service users are admitted following an assessment of their needs. The relative of a service user said, “My sister and I were taken round the home and made very welcome.” Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 9 Without exception, all service user questionnaires stated that they receive enough information about the home before deciding it is the right place for them. A relative commented, “The whole team have been very supportive during the transition from home/ hospital to care home.” Manor Croft Nursing Home DS0000001090.V322081.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): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user’s health, personal, and cultural needs are set out in a plan of care, and they receive the level of support they require to ensure that those needs are maintained. The medication housekeeping was generally of a good standard. EVIDENCE: Care plans were generally of a good standard and set out in detail the action that needs to be taken by care staff, to ensure that the health, personal and cultural needs of the service users are met. There was also evidence that they had been reviewed and updated. However, the documentation is pre printed, and on two occasions staff had referred to a general care plan, but there was no care plan seen. It was evident from the records that the plans referred to on these occasions were not required. In relation to care records nursing staff should refer to the Nursing & Midwifery Council, “Guidelines for records and record keeping.” “Patient & client records should: Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 11 Be factual, consistent and accurate.” The daily record was an account of the care the service user received and any untoward incidents/ accidents. Unfortunately, the record did not include when the next of kin of the service user had been informed of the incident/ accident. Unless there is documented evidence to suggest otherwise, the next of kin of a service user should be notified when an incident/accident has occurred. A relative of a service user contacted the Home, and Commission to express their concerns that they had not been notified when an incident involving their relative had occurred. The manager sent a letter of apology for not informing them. Two of the service user questionnaires said that they usually receive the care and support they need. The remaining questionnaires said that they always receive the care and support they need, and this was also reflected in what the service users said when spoken with. One service user said, “The care is of a very high standard exceeds expectations and is administered by wonderful caring staff. The four questionnaires returned from the doctors stated that staff demonstrate a clear understanding of the care needs of service users, and that they are satisfied with the overall care provided to service users within the home. The manager audits the medication and medication records monthly, and as part of this inspection an audit was also carried out. In relation to one service users medication, the amount of medication recorded on the drug chart and that what should have been left in the bottle was incorrect. Due to the dose of the medication changing on a daily basis, the manager is advised to check the individual service users medication on a weekly basis. The drug refrigerator had a build up of ice in side it, and should be defrosted. Manor Croft Nursing Home DS0000001090.V322081.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): 12 – 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, religious and recreational interests and needs. Service users are encouraged to maintain contact with family and friends, and they visit on a regular basis. Service users also receive a varied, appealing balanced diet, which is suited to individual assessed needs, and in pleasant surroundings. EVIDENCE: Prior to admission the social interests of the service user is recorded on the pre admission assessment, and provides a basis for the types of activities that the home provides. A list of daily and weekly activities is displayed in the entrance of the home, and service users are informed on a daily basis. Separate records are kept of the activities that individual service users are involved in, and this includes an evaluation of how the activity was enjoyed. Service users were seen to be enjoying playing bingo at the time of the visit, and a number of staff were seen to respond to service users in a kind and caring manner. Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 13 Ministers from different churches visit the home monthly and hold a service. A daily house newspaper is delivered to the home, and service users can order newspapers/magazines of which they are individually charged. Service users are encouraged and supported to keep in contact with their friends and relatives, and visitors are always made to feel welcome. On the first floor of the home there is a small kitchen where visitors can make a drink. Service users commented on how they enjoyed the food, and the menus offered variety and choice. Food preferences and diets are also taken into consideration when planning the menus. A mealtime was observed from a distance, and staff were seen to be assisting service users with eating in a dignified manner. Four questionnaires from service users commented that they always liked the meals. One person said that they had a healthy appetite due to the encouragement of the staff. Two questionnaires commented that they usually liked the meals, and one person said, that the meals for diabetics had improved recently, with more choice. They also said that it was good to have their meals in the dining room. Manor Croft Nursing Home DS0000001090.V322081.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): 16 & 18 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 clear complaints procedure that is simple, clear and accessible. Residents are protected from abuse. EVIDENCE: Complaints are recorded, and a complaint had recently been received regarding not informing relatives about a fall. The manager sent a letter of apology to the relatives. Please also refer to standard 7, care documentation about the incident, and a recommendation has also been made to the provider. Staff have received abuse awareness training, and further training dates have been arranged. Staff were also aware of the procedure to following if they suspected that an incident of abuse had occurred. Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely environment and well-maintained environment. The premises are clean and systems are in place to control the spread of infection. EVIDENCE: The home is in a good state of repair and decorative condition. Service users are encouraged to bring small items of furniture and memorabilia into the home, and a number of bedrooms had been individualised with belongings, and reflected the personalities and tastes of the people living there. Since the last inspection the lounge and staircase carpet have been replaced. Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 16 The premises were clean and systems are in place to control the spread of infection. The Commission had received a concern that there had been an odour in one of the bedrooms; there were no unpleasant odours at the time of the visit. Four out of five questionnaires commented that the home is fresh and clean. One said that on one occasion there was food on the carpet, but usually the home is nice and clean, and one service user said that sometimes there is a smell of urine, especially in the bathroom. The registered person is requested to confirm in writing that the work identified in the fire safety officer’s reports dated 14th March and 23rd August 2005 has been completed. Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing levels and skill mix were sufficient to meet the number and needs of service users. Service users are supported and protected by the home’s recruitment practices. Staff are also trained and competent to do their job. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users in the home. Five out of eight relative’s questionnaires stated that there were always sufficient numbers of staff on duty. 50 of care staff have an NVQ level 2 or equivalent. The registered person operates a thorough recruitment process, ensuring the protection of service users. Staff confirmed that they had had induction training within 6 weeks of their employment, and were able to say what the induction included. The information was also recorded in the staff training files. Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 18 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): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of people living and working at the home are promoted. EVIDENCE: The manager is a registered general nurse, and has many years experience of working within a nursing setting. She has also achieved a NVQ level 4 qualification in management and care. A quality assurance audits of all care records takes place every 4-6 weeks, and a number of quality other audits take place each month in order to monitor specific areas such as complaints, accidents, and weight loss. A nominated person from the organisation carries out monthly management visits to the home. The purpose of this visit is to ensure that the home is Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 19 meeting its objectives. A report is then produced, a copy of which is forwarded to the Commission as evidence. In addition to the above, quality assurance questionnaires are sent out to service users and their relatives. The manager said that the questionnaires are returned to the company’s head office, and then are passed back to the home where they are discussed at the residents/ relatives meetings, which take place approximately every 3 months. The results of the surveys are not published or made available to prospective service users. Information provided by the home prior to this inspection indicates that the servicing of equipment takes place on a regular basis. Weekly fire alarm and emergency lighting are tested weekly, and staff receive regular fire training and drills. There was also evidence to suggest that all staff have had movement and handling training. Satisfactory records are maintained for accident reporting. Finances were not inspected on this occasion. Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 20 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 ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 X X X X X X 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 3 X 2 X X X X 3 Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 21 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 OP19 Regulation 23 Requirement The fire safety work as outlined in the fire safety officer’s report dated 14th March 2005 and subsequent visit on 23rd August 2005, must be completed. The manger confirmed that this has been addressed. The registered person is requested to confirm in writing by 30/03/07 that the work is complete. Timescale for action 30/03/07 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 In relation to care records nursing staff should refer to the Nursing & Midwifery Council, “Guidelines for records and record keeping.” “Patient & client records should: • Be factual, consistent and accurate.” DS0000001090.V322081.R01.S.doc Version 5.2 Page 22 Manor Croft Nursing Home 2. 3. 4. 5. OP7 OP9 OP9 OP33 Unless there is documented evidence to suggest otherwise, the next of kin of a service user should be notified when an incident/accident has occurred. A weekly check is recommended for the dosage of the medication that may change on a daily basis. The drug refrigerator should be defrosted. The results of service user surveys should be published and made available to current and prospective users, their representatives and other interested parties, including CSCI. Standard 1.2 – The service users’ views of the home should also be included in the service user’s guide. Manor Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Croft Nursing Home DS0000001090.V322081.R01.S.doc Version 5.2 Page 24 - 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. 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