Inspection on 22/08/05 for Manorcroft Nursing Home

This inspection was carried out on 22nd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 18/01/07

Manorcroft Nursing Home 28/11/05

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 Tracey South Unannounced 22 August 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 Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Manor Croft Nursing Home Address Old Bank Road Dewsbury West Yorkshire WF12 7AH 01924 467521 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) Tri Care Homes Limited Ms Juliet Robbins Care home with nursing 40 Category(ies) of 40 x Old age (over 65 years), 2 x Terminally ill registration, with number (over 65 years) of places Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 9 March 2005 Brief Description of the Service: Manor Croft is a purpose built nursing home providing nursing care for up to 40 older people. The home is owned by Tri-Care Homes Ltd. 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. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection carried out on 22nd August 2005. The inspection took place over 6 hours. There were 39 residents living at the home, 4 of which were spoken to and they provided information for this report. Care records and staff personnel files were examined. A tour of the home was carried out which included a small number of bedrooms. What the service does well: What has improved since the last inspection? Good progress has been made with NVQ qualifications. The social care needs are now being considered by the staff and are included in the care plans. Recruitment of staff is thorough and is aimed at protecting vulnerable adults. Thorough recruitment procedures have resulted in a much higher calibre of staff being employed within the company. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 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 Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 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) 3,4,5 The home’s admission procedures are good. All prospective residents are fully assessed before they move into the home. Prospective residents and their relatives are encouraged to visit the home prior to admission, so they can assess whether the home is suitable. EVIDENCE: The manager and senior members of the team are responsible for carrying out pre-admission assessments. The manager spoke of the importance of carrying out thorough assessments in order to determine whether the prospective resident is suitable for the home and that staff can meet their needs. A new admission was due to take place two days after the inspection. The assessment in place contained detailed information about the resident although the care plan had not yet been completed. It was clear from speaking to residents and through interactions observed during the day, that the needs of the people living at the home are being met. Residents said the staff were very kind and supportive. Residents and staff appear to share a good relationship with each. Residents spoken to referred to “my carer” when explaining the care they received by individual staff. A Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 9 number of thank you cards were seen displayed in the home. The cards were from relatives thanking the staff for the care their loved ones had received whilst living at Manor Croft. The manager confirmed that they encourage prospective residents to come and have a look around the home, although it is usually the relatives that visit. This gives people the opportunity to see the home for themselves and make an informed decision about its suitability. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 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 standard(s) 7,8,10,11 Care plans are detailed and give staff the information they required to meet resident’s needs. The health care needs of residents are being met. EVIDENCE: Each resident has a care plan in place. The care plan clearly sets out the needs of that person including the action and support required by staff to ensure those needs are met. Daily records provide evidence that the needs, as identified in the care plan, are being met. The last inspection report recommended that the social care needs should be included in the care plan. This has now been addressed. Further development of this should continue to ensure that specific preferences of individual residents are acknowledged and acted upon. Care plans are reviewed each month. There was very little evidence that residents or their representatives had been involved in the care planning process. There was good evidence in place that residents are able to access other health care services. Records of GP visits are maintained as well as other professional visits that take place. A number of health care assessments are completed when the resident is first admitted; these then remain under regular review. Individual risks assessments are completed when a risk is identified. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 11 A number of residents have bed rails in place and appropriate risk assessments are put into effect and kept under review. Staff explained there were no residents with pressure sores at the present time. Specialist equipment, used as a preventative measure was seen to be in place. All the rooms at Manor Croft are single. The bedrooms are seen as the private space of each resident and this is respected by staff. Those residents spoken to explained how they are treated with respect. Some residents have their own telephone in their room. Relatives and friends can visit the residents at any time and are able to see them in the privacy of their own room or any of the communal areas available. The residents at the home looked well cared for. Care plans do not contain information about resident’s wishes regarding the care and support they want during illness and following death. This needs to be addressed. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 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 standard(s) 12,13,14 A good range of activities and entertainment are made available to residents. Relatives and friends of residents are made to feel welcome when they visit the home. Residents are able to bring personal possessions with them on admission. EVIDENCE: Residents confirmed that they are able to choose how they spend their day. They said there are no restrictions put on them and they are able to go to bed and get up as they wish. Some of the residents said they preferred to spend the majority of their time in their own room, whilst others enjoy the company of others. Entertainment is provided and residents choose whether or not they join in. The residents continue to benefit from “Pets as Therapy” who visit the home each week. The manager explained how money raised from a recent garden party has been donated to the above organisation. Forthcoming events are displayed in various parts of the home. The manager explained that there are now more activities taking place and residents who would not normally join in, have recently done so. The interaction between residents and staff is very positive. The atmosphere at the home is very friendly and relaxed. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 13 A residents’ meeting recently took place in the home and it was clear from reading the minutes that the views of the residents are taking into consideration. The ideas raised by residents have been put into action. Residents made comments about the food and their comments were then passed onto the cook. Residents said that their visitors are always made to feel welcome and are offered refreshments by the staff. From examining the visitors book it was clear that the home receives a number of visitors on a daily basis. Whilst speaking to residents in their own rooms, it was evident that they are encouraged and able to bring in their own personal possessions with them. The bedrooms are tastefully decorated and provide a comfortable and homely environment. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 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 standard(s) 16 The home has a good, effective complaints procedure in place. EVIDENCE: There have been 5 complaints received since the beginning of 2005. The manager takes complaints seriously. All complaints are followed up and complainants are notified, in writing, as to the outcome of the investigation. The complaints procedure is displayed in various parts of the home. Residents explained how they would approach either the manager or a member of the senior team should they wish to make a complaint. All residents were confident their concerns would be dealt with effectively. None of the residents spoken to have ever felt the need to make a complaint. The Area Manager for Tri-Care Homes Ltd is currently investigating an adult protection matter. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 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 standard(s) None of these standards were assessed. EVIDENCE: Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 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) 27,28,29,30 There are enough staff on duty to meet the needs of service users. New staff are thoroughly checked to ensure they are suitable to work with older people. EVIDENCE: The current staffing levels are set at: AM – 2 trained nurses and 7 care staff PM – 1 trained nurse and 6/7 care staff NIGHTS – 1 trained nurse and 3 care staff The nursing and care staff are supported by kitchen staff, domestic and laundry staff. There is currently one vacant post on nights. There are 27 care staff employed at the home, 12 have achieved NVQ level 2 qualifications. Seven staff are currently working towards their NVQ level 2, with a further 3 staff working towards NVQ level 3. The manager spoke of the benefits of Tri-Care having their own staff agency, allowing for a more consistent approach when covering shifts, which the residents benefit from. She also explained that the introduction of sickness and absence procedures has seen a decrease in the amount of people off work. The manager felt that staff morale was very good with all staff working together as a team. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 17 Staff and residents do appear to interact very well and there is a mutual respect between them. Residents spoke very highly of staff. Tri-Care provide training to its staff. A number of training courses have been made available this year. Staff have attended the following, fire training, infection control, health and safety, moving and handling, basic food hygiene, elder abuse, emergency first aid. Senior staff have received training in recruitment, discipline and grievance and staff supervision. Recruitment of staff is thorough. All prospective staff undergo an interview and employment checks prior to appointment of post. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 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 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) 31,38 The home is well managed. There are clear lines of accountability within the home. EVIDENCE: The manager, Juliett Robbins, is a well liked and respected individual and has been in post over 12 months. Residents in particular, spoke of nothing but praise for the manager and the senior team. The manager continues with her own self-development and has attended a number of study days. She has successfully completed NVQ level 4 and intends to undertake further training, relevant to her post, in the near future. The manager is a very caring person and communicates well with residents, staff, relatives and other professionals who visit the home. The manager is supported by Julie Wright, the newly appointed Area Manager for Tri-Care. The home has good health and safety measures in place. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 19 Fire safety work remains outstanding. Consultation between the fire safety officer and the Area Manager of Tri-Care has recently taken place. The fire safety officer is awaiting confirmation of when the fire safety work will be completed. An action plan outlining the timescales for completion must be forwarded to the CSCI within the next 4 weeks. The last fire drill to take place was 13th October 2005. A fire drill must take place immediately. The manager was also reminded to ensure that at least 2 fire drills take place each year to ensure each member of staff attends. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 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 CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION x x x x x x x x 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 x 3 x x x x x x 1 Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 21 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. Standard OP38 Regulation 23 Requirement A fire drill must take place immediately. And thereafter the manager must ensure that at least 2 fire drills take place each year to ensure each member of staff attends. The fire safety work as outlined in the fire safety officers report dated 14th March 2005 must be completed in accordance with the timescales agreed. Timescale for action 22 August 2005 and thereafter 2. OP38 23 Action plan to be sent to CSCI by 24th September 2005. 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 OP11 Good Practice Recommendations Care plans should contain information about residents wishes regarding the care and support they want during illness and following death. Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 22 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Manor Croft Nursing Home J51J01_s1090_Manor Croft_v229070_220805.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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