Inspection on 17/06/05 for Mansfield Manor Care Home

This inspection was carried out on 17th June 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

Mansfield Manor Care Home 11/01/07

Mansfield Manor Care Home 28/11/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Mansfield Manor Care Home 30/32 Chesterfield Road Mansfield Nottinghamshire NG19 7AD Lead Inspector Meryl Bailey Rob Cooper Unannounced 17 June 2005 13:00 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. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mansfield Manor Care Home Address 30/32 Chesterfield Road Mansfield Nottinghamshire NG19 7A 01623 631163 01623 631163 info@mansfieldmanor.co.uk Sherwood Healthcare Limited 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) Cheryl Brown - application being processed Care home with nursing 38 Category(ies) of DE Dementia x 8 registration, with number OP Old age x 30 of places Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within categories OP (30) or DE (8) within a total registration of 38 beds. Date of last inspection NA Brief Description of the Service: Mansfield Manor is a purpose built care home close to Mansfield town centre. The entrance is accessible for wheelchairs. The home is registered for Nursing, but this service is currently not provided and nine places remain vacant. A service is, though, offered for older people and those with needs relating to Dementia. Accommodation is provided on three floors, accessible with a passenger lift, and all bedrooms have ensuite toilet and wash basin facilities. Two double rooms are provided for couples who choose to share, but all other rooms are single. There are spacious communal areas and seating areas are laso provided outside. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and conducted by two inspectors during one day. The inspection followed two recent anonymous calls to the Commission regarding concerns about staffing levels. 28 of the current service users were at home and one was in hospital. Four staff were seen during two shifts. The manager was not on duty, but arrived at the home during the inspection. The home had nine vacancies. Some service users, relatives and staff gave their views about the care provided. The communal areas of the home were inspected and a sample of bedrooms was also seen. What the service does well: 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. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 6 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 Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 7 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) 1 and 3 Information is available about the service in the Statement of Purpose and Service User Guide, but this needs to be updated, as some information is misleading. Needs are assessed prior to admission and care is planned to meet the needs identified. EVIDENCE: The Statement of Purpose and Service User Guide are issued to every service user. A copy of these was seen in a service user’s bedroom. The service is described as offering nursing care and this is not true at the present time. Some good information is given about staff and their qualifications. However, some staff have recently left the home. Social work assessments of needs at admission were found on some service users’ files. The manager stated that these were always obtained for service users recently admitted. There was other assessment material present on files seen and needs identified were addressed in care planning. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 8 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, 9, and 11 Care plans are generally clear covering a wide range of needs, taking account of risks. Health needs are well monitored and medication is well organised. Arrangements in the event of death are not fully addressed in care planning. EVIDENCE: Four service users’ files were examined and consistently clear care plans were contained in each one. Each need identified in assessment was addressed with some clear instructions for staff to follow. Reference was made to healthcare needs that are met by the community nursing team. The manager is a registered nurse, but there are currently no other nurses within the staff team. None of the files examined identified needs for 24 hour nursing care and the manager confirmed that she was not currently admitting anyone with such needs. Risk assessments were recorded with appropriate actions to take to reduce risks associated with moving and handling, continence, falls, pressure areas and nutrition. There was also evidence of monitoring weight. Some service users had an understanding of the content of their care plans. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 9 Medication was well managed with secure storage provided in the treatment room. A lockable trolley is used to transport medication to administer to service users in the communal areas or their bedrooms. The administering of medication was observed and appropriate procedures were being followed. Staff responsible for medication have received training from People’s College, Nottingham. The staffing rota showed that on some shifts appropriately trained staff were not present, but the manager stated that arrangements are made to cover this task (see under standard 27). Admission forms contain a section concerning arrangements in the event of death. However, these were not fully completed on the four files examined at this inspection. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 15 A range of activities is provided and families are welcomed at Mansfield Manor. Meals are well presented, varied and take account of individual needs and preferences. EVIDENCE: An activities worker is employed on a part time basis and a programme of daily activities is displayed on the board in the reception area. Board games, music and movement, quizzes and bingo are included. None of these activities were seen during inspection. Service users’ files contained information about life histories and interests. The Service User Guide gives information about regular visits from the local clergy. Two relatives gave their views and said they were always made welcome in the home. Service users spoke about visits from family members and trips out with them. Service Users were very complimentary about the food provided. There is always a choice and the lunch menu for the day was displayed on a board in the spacious dining room with appropriate drawings to illustrate the choice available. One service user with diabetes said that her specific dietary needs were met. Tea was observed and a choice was given of the content of sandwiches and amounts. Discreet support was given to those requiring assistance with eating. Machines to dispense snacks and drinks are provided in the dining room together with a refrigerator for service users own use. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 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 standard(s) 16 There is a clear complaints procedure in place, which is being followed. EVIDENCE: The complaints procedure is contained within the Service User Guide, which is issued to all service users. Another copy of the procedure is on the notice board in the reception area. Relatives spoken with said they know how to make their concerns known and would speak to the manager or owner. One had done this in the past and felt the complaint was taken seriously. Records of complaints were not seen during the inspection. Two calls have recently been received at the Commission expressing concerns about staffing levels. This issue was addressed at this inspection (see under standard 27). Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 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 standard(s) 19, 21, 22, 24 and 26 A well-maintained environment is provided. Some areas are not accessible to unsupervised service users. There is suitable equipment provided to meet the needs of older people in all areas of the home and sufficient toilet and washing facilities are available. Individual rooms are comfortable and the home is clean throughout. EVIDENCE: A tour of the premises was made, but not all bedrooms were seen. The home was found well maintained, clean and fresh. The premises were built for the purposes of a care home and facilities are on three floors, accessible by stairs and a passenger, shaft lift. The ground below is sloped and part of the lowest floor is below ground level with no natural light. The quiet lounge and an activities room are within this area and were not in use by service users during this inspection, but the manager reported that the activities room is used for smoking by two service users who are supervised by staff and for hairdressing. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 13 The laundry is also situated here and was appropriately equipped, though it is recommended that the door be locked when not in use, due to substances hazardous to health being kept there (see under Standard 38). There is a sluice room on each floor. The lounges and dining room are spacious and well decorated. Individual rooms seen are well equipped to meet individual needs and service users are very pleased with the space provided. The two double rooms are occupied by couples. One couple said they were very pleased with this arrangement. The call alarm system was seen in action and is available in all rooms to call for assistance. Toilets and bathrooms are also appropriately equipped including raiser seats, “Parker” bath, manual bath seat and walk in shower. Some continence pads were in opened bags on shelves and it is recommended that these be stored more discreetly. A hoist was seen available on each floor. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 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 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 and 29 Insufficient staff are provided to meet the needs of the service users at all times. Current staff work hard to meet needs, but are stressed and tired. Recruitment practices have not demonstrated that protection of service users is adequate. EVIDENCE: The rota showed that there was one senior care and three other care staff on duty from 7.15am to 1.30pm, then one senior and two care staff for the afternoon shift until 7.45pm and two carers through the night. On the day of inspection, one of the care staff was escorting a service user to hospital and at 1.30pm this left only the senior and one care staff on the premises to meet the needs of the remaining 28 service users until the care staff returned. Service users’ records showed that two of the service users are assessed as “Very High Dependency” and twelve are “High Dependency”. The other seventeen are “Residential”. Some care plans stated “two to three staff to transfer” a service user and the manager gave information that two service users needed to be supervised in the smoking room. This leaves insufficient care staff to meet the needs of other service users. Staff were observed rushing around and those spoken to said that they are always very busy and feel under stress. Additionally, at weekends, one of the care staff has to cover kitchen duties from 4.30pm, leaving two for care duties. Examination of the staffing rota together with a list of those trained in medication, showed that some shifts with no staff trained to administer medication. However, the manager stated that trained staff, including herself, come to the home at medication times to Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 15 cover this task when needed. Medication records had all been signed by those trained to do so. The registered person was required to immediately provide consistent numbers of staff to meet the needs of all service users at all times. Vacancies for care staff have been advertised and four new applicants are appointable, but the manager is waiting for the outcome of Criminal Records Bureau checks and references. No agencies have been used to supply temporary staff. The staffing records of four current members of staff were examined and for the two most recently appointed staff, Criminal Records Bureau checks had not been carried out for this employment and one had only one reference on file. Other staffing files did not contain all appropriate information relating to identity and history (see under standard 37). Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 16 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, 37 and 38 The manager is unable to discharge her responsibilities fully due to covering care duties during staff shortages. Health and safety in the environment is generally promoted, but some additional action is needed to reduce all risks. EVIDENCE: The manager has applied for registration with the Commission and this application is being processed. She is a registered nurse and has previous management experience. Due to staff shortages the manager’s hours are currently taken up with care duties, but responsibility for service users’ records is shared with other senior staff. All records seen, with the exception of those relating to staffing, were well maintained and presented. However, records of hot water temperatures recorded by the handyman showed all outlets at a consistent temperature of 34C although the temperatures appeared much higher. The recommended temperature for hot water from taps is around 43C. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 17 Guidance from Environmental Health should be followed when monitoring water temperatures. Also, substances hazardous to health within the laundry room should be held securely. Other risks within the environment appear well managed. The openings of all windows are restricted for safety and security. Doors are alarmed and fire safety equipment was fully checked in December 2004. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 18 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 2 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 4 COMPLAINTS AND PROTECTION 3 x 3 3 x 3 x x STAFFING Standard No Score 27 1 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x x x x x 2 2 Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 19 Not applicable 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 1 Regulation 6 Requirement The Statement of Purpose and Service User Guide must be revised to reflect the service currently provided and copies sent to the Commission. The registered person must demonstrate how staff hours are calculated to meet the needs of current service users. The registered person must provide consistent numbers of staff at all times. The registered person must ensure new Criminal Records Bureau checks are carried out on all new staff and that two satisfactory references are always obtained prior to employment at the home. The registered person must ensure full records are held on staff in the care home as specified in schedule 4.6 of the care Homes Regulations. Timescale for action 31st July 2005 2. OP 27 18(1)(a) 24th June 2005 24th June 2005 31st July 2005 3. 4. OP 27 OP 29 18(1)(a) 19 5. OP 37 17(2) 31st July 2005 Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 20 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. 3. 4. 5. 6. 7. Refer to Standard OP 11 OP 21 OP 27 OP 27 OP 31 OP 38 OP 38 Good Practice Recommendations Complete the section concerning arrangements in the event of death on admission forms. Store continence pads more discreetly and not in opened bags on shelves in communal toilets. Clarify on the staffing rota who is responsible for medication. Use an agency to provide staff when required. Ensure the manager has working hours dedicated to the management of the service. Follow guidance from the environmental health officer regarding the checking of water temperatures. Lock the door of the laundry when it is not occupied. Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Mansfield Manor Care Home C53 C03 S62255 Mansfield Manor V234201 170605 Stage 4.doc Version 1.30 Page 22 - 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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