Inspection on 28/11/05 for Manorcroft Nursing Home

This inspection was carried out on 28th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Manorcroft Nursing Home 18/01/07

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 Manorcroft Nursing Home Old Bank Road Dewsbury West Yorkshire WF12 7AH Lead Inspector Tracey South Unannounced Inspection 28th November 2005 10:10 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 Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 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. Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manorcroft 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 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 Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2005 Brief Description of the Service: Manor Croft is a purpose building 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. Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 4 hours. There were 40 residents living at the home. Four residents, 1 relative and 5 members of staff were spoken to and they provided information for this report. A tour of the home was undertaken and the documents inspected included, medication records, resident’s accounts, menus, training data and quality assurance systems. What the service does well: What has improved since the last inspection? Care plans have been updated to include details of the arrangements to be followed when residents are ill and or following death. Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 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. Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 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 Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 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): None of these standards were assessed on this occasion. EVIDENCE: Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 9 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): 9, 11 Resident’s medication is well managed. EVIDENCE: Medication records were examined and it was clear that residents receive their medication at the correct time as prescribed by the GP. The nursing staff are responsible for administering medication. The records in place were found to be neat and tidy and easy to follow. Two of the senior nurses are responsible for re-ordering medication. All medication is accounted for. New arrangements have been made for the disposal of surplus medication as the pharmacy providing the medication no longer deals with the disposal of medication in nursing homes. Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 10 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): 15 The meals at the home are good offering choice and variety. EVIDENCE: The lunchtime meal was observed. Residents took their meals in the dining room or in their own room. Dining room tables were suitably laid and serviettes were available. Residents said the food was good. There are choices available for every meal. However, some residents were not aware of the meal on offer that day. Staff need to make sure that people are made aware of the meal on offer to enable them to choose an alternative if they wish. Those residents requiring assistance with their meal were supported appropriately. The cook explained that new menus are currently being devised, offering a wider range of choices. There will be at least four choices available at both lunchtime and teatime. One relative, who visits each day, at lunchtime, said the meals are very good. The relative explained how he visits his partner and provides assistance with feeding her. He enjoys being able to still participate in some aspects of his partner’s care. Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 11 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): 18 Residents are protected from abuse. EVIDENCE: All prospective staff are checked against the Protection of Vulnerable Adults register prior to them starting work. The manager explained that approximately 40 staff have undertaken adult protection training. The training has been provided by an external training agency. Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 12 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, 26 Residents live in a well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: The home was clean and tidy throughout. There was one unpleasant odour noted in one of the bedrooms, this was pointed out to the manager during the inspection. The manager explained that there are difficulties with this particular bedroom as the occupant has continence problems. However, the cleaning staff are aware of this and the bedroom carpet is cleaned on a regular basis. The feel of the home is very homely, warm and comfortable. Residents are able to walk around the home freely and there are plenty of comfortable places to sit whether it is in the lounge areas or the landing/reception areas. The home itself remains in good repair and the standard of the décor is good. The manager has highlighted areas within the home in need of refurbishment, Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 13 that is, replacing carpets and furnishings in the dining/lounge areas. It was noted that the carpet on the main staircase is threadbare in places. The same carpet on the first floor landing is worn and tape has been applied to prevent people tripping over. This carpet should be replaced. The fire safety officer visited the home on 23rd August 2005 and highlighted outstanding fire safety work. The manager was aware that there has been some fire safety work carried out but was not sure of the full extent of works outstanding. The organisation must provide an action place to the CSCI stating when all works will be completed by. The laundry is sited on the first floor accommodation. There are 2 industrial washers and dryers. The washers have a sluice programme to deal with soiled linen. Staff follow infection control procedures, protective clothing is worn by staff when dealing with clinical waste. Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 14 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): None of these standards were assessed on this occasion. EVIDENCE: Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 15 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): 33, 35 The home is run in the best interests of the residents. Resident’s financial interests are safeguarded. EVIDENCE: Each year the home sends out questionnaires to residents and staff. The manager explained that this year’s questionnaires have been sent out and completed questionnaires have been sent to head office for evaluation. The manager is proactive in seeking the views from people who live at the home. A resident’s meeting is due to take place on Friday 2nd December 2005, this is the second meeting of its kind. The purpose of the meeting is to discuss Christmas arrangements as well as any other matters the residents wish to discuss. The manager explained that the first meeting took place in June 2005 and was well attended by the residents. There are a small number of relatives who also attend the meeting as they act as advocate on behalf of their Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 16 relatives. The manager said that she found the meetings useful and welcomes feedback from residents on how they can improve facilities and services provided at the home. A newsletter is produced after the meeting has taken place, and includes details of the issues discussed. Small amounts of monies are held on behalf of residents. Five resident’s monies were checked. All of which were found to be correct. Any transactions made are recorded in writing and receipts are kept in respect of any money spent. Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 17 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 X X X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 18 yes 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 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. An action plan must be sent to the CSCI by 30/12/05 indicating when this work will be complete. Timescale for action 30/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP15 OP19 Good Practice Recommendations Residents should be made aware of the meal on offer to give them the opportunity to choose an alternative if they wish. The staircase carpet should be replaced as it is threadbare in places. Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Brighouse Area Office 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 Manorcroft Nursing Home DS0000001090.V254484.R01.S.doc Version 5.0 Page 20 - 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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