Inspection on 15/11/05 for Siegen Manor

This inspection was carried out on 15th November 2005.

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

Siegen Manor 25/04/07

Siegen Manor 04/05/05

Siegen Manor 16/11/04

Siegen Manor 04/05/04

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 Siegen Manor Wesley Street Off Odd Fellow Street Morley Leeds LS27 9EE Lead Inspector Kathleen Firth Unannounced Inspection 15 November 2005 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 Siegen Manor DS0000033232.V264616.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. Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Siegen Manor Address Wesley Street Off Odd Fellow Street Morley Leeds LS27 9EE 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 2536116 0113 2536155 Leeds City Council Department of Social Services Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: Siegen Manor is a purpose built home for older people located near the centre of Morley, south of Leeds. Leeds Local Authority manage and operate the home and there is a day centre attached that is managed and operated separately from the home. The home is divided into four wings each with sitting, dining areas, a small kitchenette and bathrooms. Walk in showers and assisted bathing facilities are available. There is a well-equipped visitors lounge where residents can sit with their families or use for private visits. Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over four hours by one inspector on Tuesday 15th November 2005. The inspector looked around the building, spoke with nine residents, four members of staff and three members of the management team, examined residents’ records including care plans, menus, staff rosters, staff files, the Service User Guide and Statement of Purpose. Staff and residents were helpful throughout the inspection and joined in the process. The manager was present for part of the inspection and a Care Officer assisted the inspector before her arrival. What the service does well: All residents have a comprehensive care plan in place with all their needs clearly identified. Tasks required to be done by staff to meet these needs are recorded and where required risk assessments are in place. Communication at the home is very good and staff showed a good awareness of the residents’ needs. Regular staff and residents meetings are held with the manager and minutes of these are made available to everyone. Minutes of the residents’ meetings are taped in addition to being written as one resident finds this more useful. Staff supervision sessions are in place and the manager offers excellent support to staff and residents. Residents are encouraged to be independent and those spoken with on the day confirmed that staff only do the things for them that they are unable to do. People are able to go to bed and get up at the times they choose and can go out and about if this has been agreed in their care plans. Residents spoken with said that they are well looked after at the home and that staff are very kind. Everyone is happy with the meals provided although one person preferred the choice of meat served before the changes recently introduced. The home has developed very good links with a local College and High School. Students and pupils have plans to build a canopy over the courtyard area of the home. One resident recently went to the school to give a talk about his war experiences. There is a commitment to training and staff confirmed that they could access relevant courses. Individual training plans are in place alongside one for the home. Most of the staff have completed NVQ Level 2. The staff are a very committed group of people and staff turnover is very low at the home. The home offers a safe, comfortable environment for the residents with plenty of things going on to keep them interested in life. Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 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. Siegen Manor DS0000033232.V264616.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 Siegen Manor DS0000033232.V264616.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, 4, 5, 6 People are able to make an informed decision about the home from the written information they receive and from what they see on their visit to the home. No one is admitted without an assessment of need. People and their families can be sure that residents’ needs will be met at the home. EVIDENCE: The Service User Guide and Statement of Purpose given to residents are very comprehensive and contain all relevant information about the home. A copy of both is available in the foyer of the home and can be accessed by anyone visiting the home. The manager and another senior member of staff assess all prospective residents prior to admission. With the information gathered at this assessment, plus that supplied by the social workers, staff at the home are able to decide if someone’s needs can be met. Copies of all pre-assessments were seen in the residents’ files. Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 9 Following these assessments residents, relatives and representatives can be sure they will be cared for at the home and that their needs will be met. Everyone thinking about coming to live at Seigan Manor is invited to look around and spend some time at the home. Families and friends are also able to visit. If it is felt appropriate a person can have an overnight stay at the home. Residents spoken with said that they had visited the home prior to deciding to live there. Seigan Manor does not provide Intermediate Care. Siegen Manor DS0000033232.V264616.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, 8, 9, 11 Staff are aware of the residents’ needs and there is good communication amongst the staff group. Residents are treated with respect at all times and can stay at the home until their death. EVIDENCE: Care plans contain the needs of the residents and the tasks required to be done in order to meet these. The plans are clear, concise, easily understood and contained health care and social needs. Risk assessments are in place as required. Evidence was seen that the plans are reviewed and updated on a regular basis. The residents are registered with three GP practices and staff confirmed that they receive excellent support from the local Health care teams. People can keep their own doctor if they are prepared to visit the home. The District nurse visits on a daily basis to administer insulin as required by residents. Arrangements were seen to be in place for chiropody and optician visits. People receive dental treatment if it is needed. All visits by healthcare professionals are clearly recorded along with the reason for the visit, the outcome and any actions required. Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 11 Two residents manage their own medication and have signed a disclaimer to confirm this. They are provided with a lockable space to store their medication. The home has a comprehensive policy in place to manage medication on behalf of the other residents. All medicines are booked in and out with two people being responsible for returning any unused. One person is responsible for the ordering and the home uses the Boots’ system. All records concerned with medication are correctly maintained and storage is done in a safe way. Staff were seen to give out medication in an appropriate way. Residents’ wishes following their death are discussed with them and recorded by staff. If it is felt to be appropriate a resident can stay at the home until their death. Discussions are held with GPs, families and any specialist services that may be needed before the decision is made to maintain someone at the home until they die. Siegen Manor DS0000033232.V264616.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): 12, 13, 14, 15 The social, religious and cultural needs of the residents are well taken care of. Residents are able to maintain contact with family and friends. They are encouraged to be part of the decision making at the home. A good, varied and nutritious diet that takes into account individual choice is served at the home. EVIDENCE: Daily activities take place and cover a wide range of topics and interests. A recent questionnaire sent to residents about activities showed that outings, sing-a-longs and reminiscence are amongst the most popular. Entertainers come into the home and this is popular amongst the residents as is shopping and going out for lunch. A list of activities is displayed on the notice board and staff record who has attended each activity. Recently a newsletter has been started that informs all of the residents, their family and friends what is happening at the home. Residents spoken with confirmed that they have enough to do and staff were seen to be helping people follow their own chosen activities. Residents confirmed that visitors are welcome at the home. Some people go out with their families or alone if this has been risk assessed and recorded in the care plan. The local college and high school are working together to build a canopy in the central courtyard of the home and one resident recently gave a Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 13 talk about the war at the High school. The manager stated that in future if they want to do any work with and for older people they will think about doing this at Seigen Manor. People can choose to smoke if they wish and can do so in a specific area in the home. Staff keep the cigarettes if this is felt to be appropriate and residents come and ask for them. If required staff sit with residents to make sure that they are safe whilst smoking. Residents are able to go to bed and get up at the times they choose. The home offers a good, varied diet that takes into account resident’s individual choices and needs. Residents spoken with say that the meals are very good and that a choice is always offered. One gentleman said that although he feels the food is exceptionally good he preferred the way the meat used to be served before the system was changed. The meal served during the inspection was very well presented and nutritious in content. All the people spoken with said that they had enjoyed it. Siegen Manor DS0000033232.V264616.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): 16, 17, 18 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Residents can be sure that they are safe from abuse and that their rights are protected. EVIDENCE: The home has policies and procedures in place to deal with complaints and any Adult Protection issues. There have been five minor complaints since the last inspection and all of these have been resolved amicably. One resident’s care is under review and her daughter is being involved in all discussions. Complaints are recorded and handled in an appropriate manner. All staff receive training on the complaints procedure. The home has an Adult Protection policy that is in line with the one adopted by the Leeds Adult Protection Committee and staff are all trained in this. The manager is confident that staff will recognise the signs and symptoms of abuse and know how to deal with this. All residents are registered to vote and mostly do so by using the postal system. If someone wishes to go to the polling station this will be arranged. Any post delivered to residents is given directly to them and help only given if it is required. Residents and their families are made aware that they can look at any information kept about them. Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 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, 21, 22, 24, 25 The home offers a safe, well-maintained and comfortable environment for the residents. Sufficient toilets and bathing facilities are available for the residents’ use. EVIDENCE: The home is designed to provide a safe and comfortable environment offering a number of discreet sitting and dining areas as well as one large lounge where there is a bar. There is a room designated for visitors to use where tea and coffee making facilities are provided. This room has recently been refurbished and offers a very pleasant area for residents to sit with their family and friends. There is a call system throughout the home for residents to summon help if they need to. Evidence was seen of the maintenance programme being in place There are sufficient toilets near to the communal areas that the residents can use. They are big enough to allow easy access for those people needing to use mobility aids. Notices are on the doors to indicate if the toilet is in use. Soap Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 16 and towels are available in all of the toilet areas. There are bathrooms in the different areas of the home including assisted bathing facilities and walk in showers. Arrangements are in place for tracking to be fitted in one toilet, bathroom and two bedrooms following assessment of two people by the Physiotherapist and Occupational therapist. Any specialist equipment can be provided if it is felt to be necessary in order for people to remain independent. Individual bedrooms are of a good size allowing people to follow their own lifestyle. One person has a computer and was using a flight simulation programme on this at the time of the inspection. Residents are encouraged to bring their own possessions with them and evidence was seen that rooms have been personalised. Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 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, 29 Residents are supported and protected by robust recruitment procedures. Staffing numbers and skill mix make sure that all residents’ needs can be met. EVIDENCE: There were sufficient staff on duty at the time of the inspection rosters; residents and staff confirmed that this was normal practice. The home now has its full complement of staff and there are separate laundry, kitchen and domestic staff. The management team are supernumerary. Residents said that staff are very kind and considerate and nothing is too much trouble for them. Staff said that they are happy working at the home and there is a low turnover of staff. They also said that the rosters are changed if necessary to accommodate the needs of the residents. Staff files seen contained all the required documentation and confirmed that recruitment is carried out in line with equal opportunities. Leeds City Council have introduced a central recruitment process recently and the manager said she was waiting to see how this would work. POVA, CRB, Visa, work permit and references are all checked before someone is employed. Training is very important at the home and staff are able to access relevant courses including NVQ. The home has a training plan in place for each staff member as well as for the home. Staff meetings are held every three months with an agenda that everyone can contribute to. Minutes are made available for all staff. Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 34, 37, 38 The home is well managed and the interests of the residents are seen as very important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager is well experienced in working with older people and shows a good understanding of their needs. She has been confirmed as the manager of the home but is still undergoing the registration process with the CSCI. She is working towards the NVQ level 4 and will start the Registered Manager’s award as soon as she can. Staff and residents all confirmed that she is very approachable and offers them excellent support. Good interactions were seen between her, staff and residents during the inspection. Recent quality assurance audits have shown very positive results for the home and have given the manager and staff a platform to build on. Regular residents meetings are held and they are included in the running of the home. Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 19 Some residents said that they are unhappy with the sofas in one of the lounge areas and have chosen some new chairs. The manager was able to confirm this. Residents can go out and about and arrangements are in place to make sure that they are safe. One new lady likes to go to town and staff have agreed with her that if she is unable to get home by the arranged time she will go to a designated place to wait for someone to collect her. The manager takes responsibility for Health and Safety although all staff are trained in this area. Fire bells are tested weekly, fire drills monthly and any faults in the system are recorded. All equipment is checked on a regular basis. Fridge and freezer temperatures are checked and recorded twice daily. Monthly checks are made on the water system and showerheads. Certificates were seen of the boiler and the electricity system annual checks. Nothing was seen that could cause a hazard to residents, visitors or staff. Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 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 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 3 X 3 3 X STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 X X 3 3 Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Siegen Manor DS0000033232.V264616.R01.S.doc Version 5.0 Page 22 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. 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