Inspection on 28/11/05 for Mansfield Manor Care 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 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 17/06/05

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 7A Lead Inspector Steve Keeling Unannounced Inspection 28th November 2005 09:15 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 Mansfield Manor Care Home DS0000062255.V268113.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. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mansfield Manor Care Home Address 30/32 Chesterfield Road Mansfield Nottinghamshire NG19 7A 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) 01623 631163 01623 631163 Sherwood Healthcare Limited Cheryl Brown Care Home 38 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (30) of places Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 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. 17th June 2005 Date of last inspection 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, and residential care. A service is also offered for older people 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 also provided outside in a very pleasant garden area. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a 4-hour period and involved one inspector. The main method of inspection was case note tracking, this is a method of selecting service users within the home and discussing with them their expectations and experiences of living within the home environment. The case tracking method also analyses the records of the service users to ascertain if the service users identified needs are being addressed appropriately within the care home setting and that their safety and well being is being maintained. On this occasion two service users notes were case tracked and two service users were spoken with. At the time of the inspection a total of 33 residents were accommodated at the home. The manager within the unit was very helpful and cooperative thus ensuring that the inspection process progressed in a professional and efficient manner. What the service does well: What has improved since the last inspection? The main area of concern identified at the last inspection was the amount and designation of staff at the home. Concerns were identified in relation to the levels of staffing on each shift and it was highlighted that consistent numbers of staff must be provided to meet needs of the service users at all times. It was established that the current staffing arrangements are now meeting the needs of the service users adequately. Mansfield Manor Care Home DS0000062255.V268113.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. Mansfield Manor Care Home DS0000062255.V268113.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 Mansfield Manor Care Home DS0000062255.V268113.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): 1. 3. 6. The manager at Mansfield Manor utilises effective documentation to ensue service users or their representatives have information so as to make an informed choice as the suitability of the home in meeting the service users needs. Currently Mansfield Manor does not accommodate intermediate care services at this time. Not all service users documentation evidenced pre-admittance assessments and as such it could not be assured that identified needs are met at the home. EVIDENCE: At the time of the inspection it was evidenced that prospective service users or their representatives are provided with a comprehensive service users guide together with the homes statement of purpose and complaints procedure. Both documents contain specific information appertaining to the service users rights, the staff structure and designation employed within the home, how service users respect and dignity is maintained at the home and the facilities that are available for the service users enjoyment. A copy of the documentation is available in the home foyer and copies of the documentation are available in the service users bedrooms to further aid the Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 9 communication process. Mansfield Manor also produces a monthly news letter designed to highlight significant diary date relating to social events planned in the home. Documentation examined through the case tracking procedure did not evidence pre admittance assessments. In the absence of a pre-admittance assessment documentation the inspector could not establish if the initial needs of the service users had been addressed effectively at the home. A requirement was issued at the time of the inspection to ensure all service users have their pre-admittance assessments evidenced within their care planning notes. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 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. 10. The case tracking procedure established that the care plans examined did not fully address the health needs of the service users and as such it could not be established that health needs were being fully met at the home. Service users are afforded appropriate respect and dignity at the home. EVIDENCE: One case tracked service users had an elevated Waterlow Score (Waterlow is a tool to determine an individuals susceptibility to the formation of pressure ulceration). The case tracked service user had also been assessed as a “high risk” of falls together with a degree of impaired cognitive function. Care plans were not evident to address the aforementioned identified risk factors effectively and as such the inspector could not establish that appropriate interventions are taking place to ensure the safety of the service user at the home. In addressing the identified shortfalls a requirement was issued at the time of the inspection to ensure all service users have appropriate care plans formulated and evidenced within their care planning notes. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 11 Both management and staff at Mansfield Manor demonstrated a thorough knowledge of the principles of maintaining privacy, dignity and respect. Service users spoken with were very complimentary about the way staff addressed service users and stated that all the staff within the home are lovely, helpful and caring. It was evident that staff always knocked on the resident’s bedroom door before entering. Service user spoken with also stated that the staff respected their privacy and dignity when bathing or performing personal care. It was evident that service users receive appropriate assistance from care staff at the home to maintain a pride in their appearance, all service users were dressed in appropriate clothing for the season and were very presentable. One service user stated that the laundry facilities within the home are very good and that her clothes were always returned promptly and in a clean well ironed condition. The inspector witnessed care staff interacting with the service users in a very pleasant and respectful manner and it was evident that the service users were very comfortable and contented within the home environment. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 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): 14. 15. Service users are encouraged to exercise choice and control in relation to aspects of daily living within the homes environment. EVIDENCE: It was established that Mansfield Manor employs an activities coordinator in an attempt to provide service users with stimulating social activities such as bingo, dominoes, cards and movement to music. Guest entertainers also visit the home to provide entertainment for service users enjoyment. The Mansfield Manor newsletter for November 2005 highlighted social events such as firework displays, a family mince pies and sherry afternoon and a Christmas party. Service users spoken with stated that they were particularly looking forward to the Christmas party scheduled on December. A church party is also planned and service users are encouraged to attend with their relatives and friends as they wish. It was established that Mansfield Manor does not have the benefit of it own transport, in addressing the need for service users to experience interactions beyond the homes immediate environment the home utilises hired transport and it was evident that service users have recently had a boat trip from Newark on Trent. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 13 Service users stated that the food in the home is very good and wholesome. The lunch being served at the time of the inspection appeared, wholesome, and appetising. The daily menu was available for service user perusal but on examination it was evident that only one meal choice was available at the lunchtime period. Service users should be afforded a choice of meals from a least two selections and as such the Commission for Social care inspection will formulate a requirement to address the shortfall. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 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): 18. Service users stated that they felt safe in the homes environment. Staff could specify appropriate actions to be taken if they suspected abuse was happening in the home but formal training in relation to adult protection could not be evidenced although it was addressed at the time of induction. EVIDENCE: Service users within the home all stated that they felt safe and protected. The manager of the home stated that new recruits to the home are encouraged to read documentation appertaining to the protection of the vulnerable adult. It was evident that staff spoken with are aware of procedures to be followed in relation to the reporting of suspected abuse and were aware of appropriate actions to be taken if they suspected abuse was happening within the home setting. An examination of staff files did not evidenced that training opportunities in relation to the protection of the vulnerable adult is provided at the home. As such the Commission for Social Care Inspection will require training to be provided to all staff at the home to ensure the safety of the service users. In ensuring that any concerns are addressed effectively at the home the manager utilises a questionnaire to establish the service users satisfaction with the facilities available at the home. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 15 The questionnaire is available in the reception area and once filled out, either by the service users or their representatives, the form will be passed to the manager. It was established that the manager of the home would attempt to address any issues of concern that the service user or their representative might have. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 16 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. Mansfield Manor provides a safe well maintained environment for service users although shortfalls were identified in the control of leginella contamination. EVIDENCE: It was evidenced that the home is maintained to a satisfactory standard throughout. It was also evidenced that external contractors perform appropriate maintenance schedule on all equipment designed of aid mobility such as wheelchairs, hoists and specialist baths. The manager of the unit could also demonstrate that bed rail checks are performed on a monthly basis, hot water outlet checks are performed on a monthly basis and window restrictor checks are also performed on a monthly basis together with the staff call system. Outside contractors are employed to chlorinate water systems to inhibit the formation of Leginella contamination, it was evident that this procedure was Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 17 last performed in October 2003 and as such the Commission for Social care Inspection will recommend that the procedure is performed as soon as possible to ensure the safety of service users at the home. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 18 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. 29. 30. The amount and skill mix is appropriate to meet the needs of the 33 service users at Mansfield Manor. The manager of the home only employs new recruits once appropriate documentation and references have been obtained. Staff received training to provide appropriate health care at Mansfield Manor but documentation appertaining to supervision sessions performed at the home was not comprehensive EVIDENCE: At a previous inspection it was established that staff employed at Mansfield Manor Care Home was not sufficient to meet the needs of the service users. It was also evidenced at the last inspection, that an inappropriate skill mix was being employed as a qualified nurse was not in attendance over the 24 hour period. The manager of the home could evidence that staffing levels are now appropriate to meet service users needs due to a significant increase in qualified nurses employed at the home. On the morning of the inspection 5 carers, and one qualified nurse was on duty, throughout the afternoon period three carers, and one qualified member of staff was on duty and the night period was covered by two carers and one qualified nurse. It was established that the manager of the home is employed on a supernumerary basis so she can manager the home effectively. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 19 Staff files contained appropriate information in relation to Criminal Records Bureau (CRB) checks and two satisfactory references. The identity of staff employed at the home could be established through appropriate documentation such as passports, birth certificate or bank statements. It was established that no new members of staff commence employment until the aforementioned documentation is in place and references are satisfactory. The inspection process allowed an the informal discussion with a senior member of the care staff employed at Mansfield Manor. It was established that she had received in house training in infection control, moving and handing, dementia care, continence awareness, health and Safety, fire prevention, first aid, health and hygiene and the safe handling on medicines. The manager ensures that staff members receive supervision from either herself or the new owner of the home in an attempt to identify and promote good care practice at the home. It was established that the documentation appertaining to supervision performed at the home was not maintained appropriately as it did not evidence all the supervision sessions performed at the home, as such the Commission for Social Care Inspection recommended that documentation in relation to the frequency and content of supervision sessions should be more comprehensive. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 20 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. 33. 35. It was evident that the manager at Mansfield Manor is professional, fit to be in charge, of good character and is able to discharge her responsibilities fully. The home is run in the best interests of the service users. Service users financial interests are safeguarded by the policies at Mansfield Manor. EVIDENCE: The manager of Mansfield Manor attained her Registered General Nursing qualification in 1977. Since that time she has gained considerable experience in both the primary and secondary care settings. Having recently registering with the Commission for Social Care Inspection as the registered manager of the home she is currently in the process of enrolling on the degree level Registered Managers Award. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 21 In the absence of a manager the day to day running of the unit is performed by qualified nursing staff, it was established that the manager is also on call should any concerns arise in her absence. It was evident that the manager promotes a friendly relaxed environment for the enjoyment of the service users and service users spoken with felt confident in the acting manager’s ability to manage the home in a clear supportive manner. It was established that a residents and relatives meetings are performed on a three monthly basis so as to identify and address any areas of concern in relation to the care afforded to service users within the home. A summery of the meetings are available on the monthly newsletter produced at the home. At the time of the inspection it was evidenced that the service users monies are effectively managed. A clear record of monitory transactions could be evidenced. The case tracked service users, monies are securely stored, in individual plastic folders an stored within a secure environment. Receipts are evident for all transactions performed, and a clear financial audit trail was evident thus protecting the service users from financial abuse. Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 22 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 4 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X x Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 3 Regulation 14 (1) (a) Requirement The registered person shall ensure a suitably qualified or suitably trained person has assessed the needs of the service users prior to admission. The registered person shall ensure after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. The registered person shall keep the service users plan under review. The registered person shall provide adequate quantities, suitable, wholesome and nutritious food, which is varied and properly prepared and available at such time as may reasonably be required by service users. The registered person shall make arrangements by training staff or by other measures to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Timescale for action 31/12/05 2 7 15 (1) 31/12/05 3 4 7 15 15 (2) (b) 16 (2) (i) 31/12/05 31/12/05 5 18 13 (6) 31/12/05 Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 24 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 19 Good Practice Recommendations The control of Leginella contamination was last performed in October 2003 and as such the Commission for Social care Inspect. The procedure should be performed as soon as possible to ensure the safety of service users at the home. Documentation in relation to the frequency and content of supervision sessions should comprehensive and maintained effectively 2. 30 Mansfield Manor Care Home DS0000062255.V268113.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Nottingham Area Office 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 DS0000062255.V268113.R01.S.doc Version 5.0 Page 26 - 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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