Inspection on 25/04/07 for Siegen Manor

This inspection was carried out on 25th April 2007.

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 15/11/05

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 Catherine Paling Key Unannounced Inspection 09:45 25th April 2007 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.V327981.R01.S.doc Version 5.2 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.V327981.R01.S.doc Version 5.2 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 2536155 0113 2536155 Leeds City Council Department of Social Services Mrs Georgina Worrall Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 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 provides personal care for up to 30 people. Nursing care is not provided and the local district nursing service provides nursing support if needed. 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. Accommodation is provided in mostly single rooms with a small number of shared rooms available. Information about the service is available in a Statement of Purpose and Service User Guide as well as a brochure. These documents are reviewed regularly to make sure that the information is up to date. The fees range from £94.45 to £ 458.86 per week. There are additional charges for hairdressing and newspapers. This information was provided by the service on the pre-inspection questionnaire completed in January 2007. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 30th June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by the people who live at the home. More information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and one inspector was at the home from 09.45 until 16.45 on 25th April 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live at the home and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the manager and the staff. A pre-inspection questionnaire (PIQ) had been completed before the visit to provide additional information about the home. Survey form were sent to the home prior to the inspection for the manager to distribute providing the opportunity for people at the home; visitor and healthcare professionals visiting the home to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A number of surveys were returned and although overall the comments were positive there were some concerns raised about staff changes; a need for increased stimulation for the people at the home and there were mixed views about the food. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The manager and her staff are knowledgeable about the need of the people at the home and understand the importance of detailed records. This is reflected in the quality of the information in the lifestyle plans. However, where there are more complex health needs, such as diabetes the information is not as detailed. Full details of care should be recorded to make sure that that care needs are not overlooked. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 7 Although night staff do have fire training they do not take part in fire drills and the manager should make sure that they do. Recommendations appear at the end of the report. 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. The summary of this inspection report can be made available in other formats on request. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 8 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.V327981.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. People have enough information to be able to make an informed choice about moving into the home. The admission process is good and includes introductory visits wherever possible. EVIDENCE: There is a range of information available to people who currently live at the home as well as those who are thinking about moving into the home. In addition to the statement of purpose and resident guide there is also a brochure. These documents are all reviewed on a regular basis; the statement of purpose was updated in January 2007. Copies of these documents can be found around the home. There are plans to change the service provision at the home to provide intermediate care and respite care for people with mental health problems. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 10 There are specific resident guides for all aspects of the proposed and current services provided at the home. People and/or their representatives are invited to visit the home to help them make a decision about moving in. Detailed information about people is gathered prior to admission. This includes the local authority assessment documents as well as information from other healthcare professionals who may be involved. The manager and her staff are very knowledgeable about the people living at the home and their specific needs. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. Health and personal care needs are met. Care plans need to be developed to make sure that staff have full details of peoples’ needs to make sure that care needs are not overlooked. People living at the home are protected by safe medication practices. The staff respect the privacy and dignity of the people living at the home. EVIDENCE: The case records of three people who live at the home were looked at in detail. All have individual plans of care in the form of a Lifestyle plan. The standard of recording information about the residents on these documents was good. There is useful and specific personal detail in the plans clearly indicating personal preferences about care needs and how these can be met. It was not always clear who had recorded the information or made additions to the plans Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 12 and entries were not always dated. Summaries of the lifestyle plans were completed and there was a record of regular reviews. The summaries provide an overview but no detail of care needs. Nutritional risk assessments had been completed and regular weights were recorded. There were regular detailed reviews carried out involving the person living at the home as well as their family. Support and guidance is also sought from other healthcare professionals when needs change and written information was included in the records although had not necessarily been included on a care plan. One person had become less mobile and a full assessment had been arranged so that they could maintain their independence as far as possible. One person was an insulin controlled diabetic and although staff had access to the district nurses’ records it was suggested that the essential information about the management of the condition should be included in the individual care records. There were clear records of the involvement of other healthcare professionals. General Practitioner (GP) visits in particular were very well documented. The Lifestyle plans had been signed by the person concerned and relatives had also been consulted. Care staff were knowledgeable about the individual care needs of the residents who said that they felt well looked after by the staff. The medication room had been re-sited recently and is still in the process of being sorted out. All the staff involved in the administration of medication have had training and receive regular updates. The local pharmacist also provides good support to the home as well as some training and update for staff. One senior member of staff oversees the ordering of drugs and all staff involved in administration share the responsibility of making sure the medication administration record (MAR) sheets are clear and up to date. Care staff and the people who live at the home share a good rapport and people are treated with respect. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. People who live at the home are able to exercise choice in their daily routines and their social expectations are met. People living at the home are provided with a varied and nutritious diet. EVIDENCE: There is a range of activities and outings available for people to join in if they want to. The planned programme of activities for the year is displayed on the wall outside the office in a clear and attractive format. A regular newsletter is also circulated with information about forthcoming activities and other issues. The manager and the staff discuss proposed activities and outings at residents meetings. The people living at the home are encouraged to continue links with the community and are supported in pursuing particular lifestyle choices. They are also supported in maintaining their religious beliefs. The close proximity of the home to the centre of Morley means that some of the people at the home Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 14 are able to go out to the town independently on a regular basis. There are also links with the local school. Visitors are welcomed at the home at any time. The people living at the home prefer visitors to avoid mealtimes but if this is unavoidable people are able to make use of the visitors lounge. There was an overall positive response in the recent survey of relatives with people saying that they felt that they were kept informed and that staff were ‘kind and caring’. The surveys completed by the people who live at the home said that they were satisfied with their care and happy living at the home. There is a wide choice of food available and the views of the people living at the home are taken into account with the menu planning. People said that the food was good. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. There is a clear complaints procedure available to people at the home. The people who live at the home feel confident that they will be listened to and can be assured that action will be taken when necessary. There are robust adult protection procedures and staff have received training. People can be assured that they are safe at the home. EVIDENCE: There is a clear complaints procedure in place. People were not necessarily aware of the complaints procedure but felt confident that they could talk to staff about any concerns and they would be taken seriously. All spoken with felt safe and well cared for at the home. The manager keeps a simple log of complaints made and action taken. The manager is proactive in dealing with issues. Some issues identified in the annual quality survey had been dealt with promptly. The subject of complaints is a regular agenda item at residents’ meetings. All the staff have received training with regard to adult protection and there is a whistle blowing procedure in place. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. People live in a safe and well maintained environment. EVIDENCE: Accommodation is single storey and there is easy level access to the home. People who live at the home and are independent in electric wheelchairs are able to come and go with minimal help. The environment is well maintained and communal lounges are situated around the home. There is a designated visitors room that has recently been redecorated and provides a bright and attractive seating area. The fenced garden area is easily accessed from the home. There are plenty of seats provided as well as tables, chairs and umbrellas. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 17 There are communal bathrooms throughout the home with assisted bathing facilities as well as fully assisted shower facilities. The toilets are near to the communal areas to allow easy access for people. The individual bedrooms are comfortably furnished and residents can choose their own décor. People are encouraged to bring their own possessions with them and rooms were comfortable with lots of personal possessions around. The planned changes in service provision have resulted in some environmental changes that were not quite complete at the time of this visit. Redecoration and refurbishment plans were ongoing and will include the communal sanitary facilities. The home was clean and tidy throughout. A control of infection policy is in place and the home employs specific people to deal with the laundry. Staff have all had training in the control of infection and good practices were in place. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The number and skill mix of staff is sufficient to meet the needs of the people living at the home. Staff are well trained and competent to meet the needs of the people living at the home. EVIDENCE: Duty rotas indicated that there were sufficient staff available to meet the needs of the residents. The care staff are supported by a team of ancillary staff carrying out domestic, laundry and catering duties with a handyman also providing day-to-day support for the staff team. There is little staff turnover with the majority of the staff having worked at the home for a number of years. The stability of the staff team means there is continuity and familiarity for the residents. There are proposals to increase the number of staff on duty throughout the 24 hour period as part of the proposed changes to the service. Applications are currently being considered. There has been very good progress in staff achievement of National Vocational Qualifications (NVQ) in care at the home. Over 80 of the care staff have Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 19 achieved NVQ level 2 in care, far exceeding the standard of 50 . Senior care staff have achieved NVQ level 3 in care. Domestic staff have also been given the opportunity to do NVQ in the relevant topics areas. All staff have formal supervision sessions and appraisal where training needs are identified. There is a clear commitment towards training and making sure that all designations of staff are equipped to carry out their roles and to care effectively for the people at the home. As part of the preparation for the change to the service there has been a programme of specific training for all the staff including dementia care; person centred care and the single assessment process. Training has been accessed through local colleges and there was already evidence throughout the home of the implementation of the training. Recruitment is carried out centrally and records held at the home are photocopies. There was evidence that the required checks are carried out before staff start work at the home. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The home is well managed. The interests of the people who live there are seen as very important to the manager and her staff and are safeguarded at all times. EVIDENCE: The registered manager provides clear leadership and stability at the home. She is very experienced and has gained an NVQ in management at level 4, the Management Charter Initiative at level 4 and will complete the Registered Managers’ Award (RMA) this year. A quality assurance system is in place and the most recent questionnaires were completed by staff and residents earlier in April 2007. The results had Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 21 been collated and made available to interested people. The manager had identified some particular concerns within the responses and had already met with people to resolve the issues. Meetings are held regularly with the people who live at the home and a separate meeting for their relatives. Relatives visit the home regularly and say that they feel that they are kept up to date with changes and events at the home. The manager also meets regularly with the different designations of staff and notes are also kept of these meetings. All the meetings notes provide evidence of the manager’s openness and willingness to involve others in the running of the home. On the day of the visit the manager was involved in a presentation to the local community about the imminent changes to the service provision at the home. The home looks after a small amount of personal allowance for some of the people. The manager and the senior staff team carry out regular checks of the money and the system is also subject to regular external audit. There is a system in place for ongoing risk assessment within the building to make sure that residents are safe. 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. It was established that although night staff have a fire lecture they do not take part in drills. Ways of addressing this were discussed and the manager gave assurances that this would be addressed. Records are kept of any accidents occurring at the home. Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 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 3 Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 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. 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. 1 Refer to Standard OP7 Good Practice Recommendations The individual records should provide detail and evidence of care with specific instructions and guidance for staff to follow. For example, in relation to the management of conditions such as diabetes. The manager should make sure that the night staff have taken part in a fire drill as part of their fire training. 2. OP38 Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Siegen Manor DS0000033232.V327981.R01.S.doc Version 5.2 Page 25 - 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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