Inspection on 15/03/06 for Manorfield House

This inspection was carried out on 15th March 2006.

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

Manorfield House 06/03/07

Manorfield House 26/10/05

Manorfield House 22/03/05

Manorfield House 24/02/05

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 Manorfield House Manor Road Horsforth Leeds LS18 4DX Lead Inspector Kathleen Firth Unannounced Inspection 15th March 2006 11:00 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 Manorfield House DS0000033211.V285501.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. Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Manorfield House Address Manor Road Horsforth Leeds LS18 4DX 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) 0113 2583561 0113 2583561 Leeds City Council Department of Social Services Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2005 Brief Description of the Service: Manorfield House is a purpose built residential home offering personal care to twenty-seven older people. It is owned and operated by Leeds City Council. The home has undergone a major refurbishment and the rooms are now all single and apart from two have en suite facilities. Accommodation is provided over two floors, the first being accessed by a passenger lift or staircase. All bathrooms have been fitted with specialist baths and equipment allowing residents to retain independence, privacy and dignity. Personal laundry is done on the premises and an outside contractor has responsibility for laundering towels and bed linen. All food is freshly prepared on the premises. The home is situated off the main road and parking is available for visitors. Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over three and a half hours by one inspector on Wednesday March 15th 2006. The inspector looked around the building, examined records including care plans, staff rosters, medication records and menus. Staff and residents were helpful during the inspection and joined in the process. Eight residents and four staff members were spoken to and one of the Care Co-ordinators was present for the whole of the inspection. The other Care Co-ordinator was present towards the end of the inspection and for the feedback. What the service does well: The atmosphere within the home is very relaxed and welcoming with staff spending time with the residents. There are large comfortable lounge areas for the residents to enjoy and be comfortable whilst following their individual pastimes. The home provides respite; short stays as well as permanent care for residents. All residents have a care plan in place that identifies their individual needs and the tasks required to meet these. Specific instructions are clearly recorded, as are any allergies. GP visits are recorded along with the reason for the visit, the outcome and any required actions. Regular staff meetings and supervision sessions are in place and communication within the home is very good with staff having a good awareness of residents’ needs. Residents spoken with said that they enjoy living at the home and that the staff are very kind and look after them well. Everyone is happy with the meals served and said that there are alternatives if something is served that people do not like. Residents say that they can go to bed and get up at the times they choose, these times are recorded in the files. Visitors can come at any time and are made welcome by staff. If agreed residents are able to go out with family and friends. Religious needs are taken care of at the home with the local Church of England holding a communion service and other ministers visiting on an individual basis. A good range of activities are offered at the home and people can choose which they want to join in with. All staff at the home are trained to be competent at their job and most staff have achieved or are working towards National Vocational Qualifications (NVQ). New people have recently been recruited to bring the home up to its full complement of staff. They will start working once all the required checks have been made and received. Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 6 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. Manorfield House DS0000033211.V285501.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 Manorfield House DS0000033211.V285501.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): 3, 4, 5, 6 People admitted to the home can be sure that their needs will be met. EVIDENCE: The manager or one of the care co-ordinators visit all prospective residents and carry out an assessment of need. Information is also obtained from the person’s social worker. Once this has been done a decision is made as to whether these needs can be met at the home. If it is felt that they can then a visit to the home is arranged. Once an admission has been agreed the person and their family can be sure that their needs will be met. Prior to admission people usually spend a day at the home and are able to meet with staff and the other residents. They are able to see the room that they will occupy at the time of the visit. More than one visit can be made if the person has any doubts about coming to stay at the home. People coming to the home for respite or short stay always visit before their first admission. Family and friends are also invited to visit the home and look around. Some of the residents spoken to had visited and found the exercise useful whilst others said it had not really influenced their decision to be admitted to the home. Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 9 Intermediate care is not provided at the home. Manorfield House DS0000033211.V285501.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, 9 The home has a procedure in place to manage the residents’ medication. Staff are aware of the residents’ needs and communication between them is good. EVIDENCE: All residents have comprehensive care plans in place that highlight their needs and the tasks required to be done to meet these. Some contain good pen pictures of the residents. The plans are clear, concise easily understood and contain healthcare, social and spiritual needs. Where appropriate risk assessments with the coping strategies are in place and these have all been updated recently. Some but not all care plans were seen to be reviewed on a regular basis. GP visits are clearly recorded with the reason for the visit plus the outcome and any actions that are required. Evidence was seen of regular weight checks where required and a Nutritional Risk Assessment tool is available for staff to use. Residents sign an agreement to have nighttime checks and this is kept in their file. None of the permanent residents are able to manage their own medication and the home has a policy and procedure in place to do this for them in a safe way. The home uses the Nomad System and the Pharmacist delivers the medication Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 11 on a weekly basis. In the main it is the officer team who deal with medication but a senior care assistant will do so if they are in charge of the shift. Most of the staff have completed an accredited course on Medication Protocol that deals with the receipt, storage, administration and disposal of medicines. Information is also given to help staff find out about side effects of particular medication. Staff at the home normally manage medication for short stay and respite people but a locked drawer is provided for them to do this if they are able and prefer to do so. A medication disclaimer is signed in these circumstances. Manorfield House DS0000033211.V285501.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): 13, 15 Residents are supported to maintain contact with family and friends. A good, varied and nutritious diet is served to residents that takes into account individual likes and dislikes. EVIDENCE: Visitors are made welcome at the home and can come at any time to see their family and friends. There has been some increase in family involvement at the home although it is still relatively small. Groups from local churches, schools, cub and scout groups visit the home. Residents are able to go out with family and friends if this has been agreed in their care plan. One man goes to the local shops unaccompanied and this has been risk assessed and agreed. The home works from a four weekly menu with the main meal being served at lunchtime. A choice of main course is offered most days with the residents able to make their choice at the time the meal is served. Hot and cold food is available at teatime. An alternative is available if a resident does not like either of the dishes offered. Staff have an awareness of residents’ likes and dislikes and do not serve them anything that does not agree with them. The home is able to cater for residents who have diabetes. The meal served during the inspection was nicely presented and nutritious in content. Specialised cutlery is available that allows residents to eat their meals independently. The Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 13 dining room is quite big and provides sufficient space for the residents to sit comfortably whilst eating their meals. There is enough space for residents who need to use mobility aids to do so safely. Manorfield House DS0000033211.V285501.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 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. EVIDENCE: The home has a comprehensive complaints procedure in place. Residents are given a copy “How to make a complaint” when they are admitted to the home and the procedure is in the Home’s brochure. There is a copy of the complaints procedure on the home’s notice board to inform visitors. There has been one minor complaint since the last inspection. This was investigated and settled amicably. Manorfield House DS0000033211.V285501.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, 22, 23, 24, 26 The home offers a safe and well-maintained environment for the residents. Specialised equipment to help residents maintain their independence is available. EVIDENCE: The home is furnished and decorated to a very good standard and is clean and hygienic throughout. There are handrails throughout the home to assist residents to walk about safely. A ramp offers easy access to the garden where residents are able to sit in the better weather. The lounges and dining room are very spacious and comfortable for the residents. A lounge where people can smoke is available and there is a conservatory where residents can sit quietly. All bedrooms are of a good size and are well furnished. Residents were involved in choosing the carpets and décor when the home was refurbished last year. People have personalised their rooms by bringing their own possessions and they have enough space to follow their chosen activities. Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 16 There are sufficient toilets around the home in addition to the en suite facilities to meet the needs of the residents. Assisted bathing facilities and walk in showers are available to make sure that residents can bathe and shower safely. The bathrooms are very spacious and tiled to a very high standard. Specialised equipment can be obtained following assessment by the Occupational Therapist to allow residents to be as independent as possible. One lady has recently been supplied with a profile bed and a special cushion that allow her to get up and out of bed independently. A bed has been made to measure for one resident because of his particular needs. Manorfield House DS0000033211.V285501.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 Staffing numbers and skill mix make sure that the residents needs can be met. EVIDENCE: The numbers of staff on duty at the time of the inspection were sufficient to meet the needs of the residents and rosters confirmed that this is usual practice. The home has fifty-five permanent and thirty maternity leave hours vacant at present. This has meant staff working extra hours and they have been supportive of each other in doing this. Agency staff have been employed to cover the gaps and this has eased the situation. Senior staff have made sure that agency staff have worked alongside regular people in order to provide continuity of care. The agency has tended to provide the same staff, which has been very helpful. There are emergency numbers where staff can ring for help if anyone fails to turn up for a night shift. Interviews have taken place to fill the vacancies and appointments will be made once all the required checks have been carried out. The Manager interviewed locally as the council had not been able to recruit within its central recruitment process. All staff undergo induction training when they are appointed. The course is accredited to TOPSS. It includes central and local input where people learn about the organisation and then about the particular establishment where they will work. Staff are given a workbook and have to complete the tasks in this before their induction is considered finished. Individuals are given the amount of time they need to complete the workbook although there is a cut off point. New staff shadow established workers as part of the induction to make sure Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 18 that they are competent at the tasks required of them. Staff are enrolled on NVQ once they have satisfactorily completed their induction. Manorfield House DS0000033211.V285501.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, 37, 38 The home is well managed, the interests of the residents are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager has many years experience working in residential care and has managed a number of homes during this time. She is due to have her “Fit person” interview with the Commission. Since coming to the home the manager has introduced some changes designed to improve record keeping. Staff are able to speak with her and discuss ideas or seek advice. She was not at the home on the day of the inspection. Residents spoken to say they are able to speak to her if they need to. All records seen were correctly maintained and up to date although confidential information about residents including their care plans should be locked away. Communication amongst the staff team is very good and a verbal handover is Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 20 given before the start of each shift. The manager takes responsibility for Health and Safety at the home although all staff receive training in this area. One Care officer has recently completed some extra training in Health and Safety and is hoping to take on some responsibilities for specific tasks. The manager carries out the monthly safety checks and fire bells are tested weekly with records kept. A maintenance man comes to the home and tests the sprinkler system on a weekly basis and again records this activity. Nothing was seen during the inspection that could cause a hazard to residents, staff or visitors. If there are any Movement and Handling issues an Occupational or Physiotherapist is asked to come and assess the resident and will then provide equipment or staff training if needed. Manorfield House DS0000033211.V285501.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 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 4 3 4 4 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X 2 3 Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 22 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 OP 29 Regulation 19 (d) (1) Requirement Up to date photographs of staff should be in their files. (Previous date of 31/01/06 not met.) Timescale for action 31/05/06 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 OP 37 Good Practice Recommendations All confidential information concerning residents should be locked up. Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Manorfield House DS0000033211.V285501.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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