Inspection on 04/05/05 for Siegen Manor

This inspection was carried out on 4th May 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 15/11/05

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 10.15 am. Wednesday 4th May,2005 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. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service SIEGEN MANOR Address Wesley Street Odd Fellow Street Morley, LEEDS LS27 9EE 0113 2536116 0113 2536155 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) Leeds City Council n/a Care Home 30 Category(ies) of PC Care home only registration, with number of places SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 18 November 2004 Brief Description of the Service: Siegen Manor is a purpose built home for older people located near the centre of Morley, south of Leeds. It is operated by Leeds Local Authority and has 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 avilable. There is a well equipped visitors lounge where residents can sit with their families or use for private visits. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over six hours by one inspector on Wednesday 4thMay, 2005. The inspector toured the building, spoke with residents, staff, management, visitors, examined residents’ records including care plans, menus, staff rosters, staff files, the Service User Guide and the Licence Agreements issued by the Local Authority. Staff, residents and visitors were very helpful throughout the inspection process and were happy to join in. Fourteen residents, six members of staff and three relatives were spoken to on the day. The Manager was present for most of the inspection and her input was very helpful. What the service does well: Each resident has a comprehensive care plan in place with all of their needs clearly identified along with the tasks needed to be done in order to meet these needs. Communication amongst the staff is very good and there is a system in place to ensure residents’ relatives/friends are kept up to date with any changes in their condition. Regular staff meetings and supervision sessions are in place and the manager makes herself available to staff. Residents are encouraged to be independent and regular meetings are held where they can put forward any ideas/concerns that they might have. The people spoken to confirmed that they can go to bed/get up at the times they choose and are free to go out with relatives/friends. Some residents said that they go out alone or with one member of staff according to what is agreed in their care plan. All residents spoken to confirmed that they are well looked after and feel able to approach the manager and staff to speak to them. They also said that although the kitchen has been out of action since August last year the main meals have continued to be excellent, and staff have done a good job under difficult circumstances. However some did state that they were bored with cold teas and were happy when informed that the kitchen is due to reopen next week. There is a commitment to training and staff members confirmed that they have easy access to relevant courses. Individual training plans are in place alongside one for the home. Most staff members have already completed or are working on NVQ. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 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 CS0000033232.V231000.R01.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 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 standard(s) 1,2, 3, 5, People thinking about using this service are able to make an informed decision from the written information they receive and from what they see on their visit to the home. EVIDENCE: The home provides all prospective residents with a brochure that contains all relevant information about the home including the services they can expect to receive. A copy of this brochure is available on the notice board in the entrance of the home. Leeds Local Authority issues each resident with a licence agreement once they move in that spells out their rights and, what the home can expect from them including all financial information. This agreement is reviewed on an annual basis and a new copy issued. Social workers provide the staff at the home with an assessment of need when a person is referred. The manager and a member of the senior team visit the prospective resident and carry out their own assessment of need. Following this the senior team make a decision about the home’s ability to meet the SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 Page 9 person’s needs. Copies of the social work assessments are kept in the residents’ files and were examined on the day of the inspection. The home’s staff do not keep a written copy of their assessment. If it is felt the home is appropriate for the person they are then invited to visit to decide if they like it and if they wish to move in. At the time of the visit the prospective resident usually has a meal and chats to residents and staff. They are also shown the room that they will be allocated. This visit may also include an overnight stay if there is any doubt that the home will be able to meet the person’s needs. Family/friends are also able to visit the home. Residents spoken to at the time of the inspection confirmed that they had visited the home prior to their admission. One relative also said that she had been to look round and had had access to information about the home before her mother had decided to move in. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 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 standard(s) 7, 8, 9, 10 All of the resident’s needs including health, social, religious and cultural needs are fully met. Staff treat residents with respect and maintain their dignity at all times. EVIDENCE: Comprehensive care plans were seen to be in place for all residents. Evidence was seen that good guidance is given to staff about the questions they ask residents, to ensure that adequate information is gained regarding needs and preferences. The needs are clearly identified in the care plans alongside the actions required to ensure these needs are met. Risk assessments are in place with clear coping strategies where applicable. There was clear evidence that the plans are reviewed and updated regularly. Health care needs are identified and visits from health professionals recorded with any relevant treatments/actions required. The manager confirmed that they have a good relationship with the local healthcare teams and that services are easily accessed. The home has a comprehensive medication policy in place. All medicines are booked in and out, a good ordering system was seen and staff were seen to SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 Page 11 administer medication in a correct manner. One resident manages their own medication following the appropriate risk assessment. The residents’ preferences and dislikes concerning activities are recorded and things organised to meet these. There are lots of activities going on including trips out. All of the residents spoken to during the inspection said that they were well looked after and that all the staff were approachable. They felt that they were treated with respect and their dignity was maintained at all times. Evidence was seen that staff knock on bedroom doors before entering and that they are sensitive when dealing with situations that could be embarrassing for people. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 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 standard(s) 12, 13, 14, 15 The social, cultural and religious needs of residents are well met. Residents are supported to maintain contact with their family and friends. Wherever possible residents are given control over their own lives and encouraged to make choices. The home provides a good nutritious diet that takes into account individual choices and preferences. EVIDENCE: A religious service is held on a monthly basis at the home and is attended by anyone who chooses to do so. Some residents spoken to said that they enjoy the service and one said they preferred to attend their own church. Religious ministers are welcomed at the home at any time and there was an interdenominational minister visiting at the time of the inspection. Residents spoken to said that they enjoy some of the activities that take place especially trips out. Some people are taken to the town centre shopping as it is fairly close to the home. One lady showed some plants she had purchased on a recent trip to a popular garden centre in the area. Trips out appeared to be very popular amongst the residents. The home is entering an “in bloom” competition and residents and staff are busy organising the garden for this. Regular resident meetings are held and one lady said that she felt they were listened to at these when they put forward their ideas or voiced concerns. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 Page 13 Relatives spoken to during the inspection said that they always feel welcome at the home and are able to discuss any concerns with staff. There is a sheet in the resident’s file where any contacts with their next of kin are recorded. Residents confirmed that they are able to go to bed/get up at the time they choose and some people who choose to have a lie in were still in bed when the inspector was looking around. They can go out with family and friends if this is their choice. There have been major problems with the kitchen at the home and meals have had to be prepared elsewhere by the cook and transported back. Residents said that this has been very difficult but said the meals have been very good despite this. They have been unable to have much choice at tea times but accept that this is not the fault of the manager or staff. Workmen were fitting power supplies to the kitchen at the time of the inspection and appliances were due to be delivered by the end of the week. The cook said that the new kitchen should be operational by May 12th. The meal served during the inspection was nicely presented and nutritious in content. Special cutlery and plates were seen to enable residents to eat their meal independently. There was sufficient space in the dining areas to allow residents to eat in comfort. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 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 standard(s) 16, 17, 18 Residents and their relatives have their view listened to, taken seriously and action is taken to resolve issues. Residents can be sure that their rights are protected and that they are safe from abuse. EVIDENCE: There is a copy of the complaints procedure in the licence agreement issued to each resident by the Local Authority and also displayed on the notice board at the home. Residents and visitors spoken to during the inspection all said that they would raise any concerns with the staff and felt confident that it would be dealt with appropriately. Complaints were seen to be recorded in an appropriate way. Staff and residents are informed via their handbook and licence agreement that staff cannot witness or benefit from residents’ wills. All staff receive training in Adult Protection and are aware of how to respond if they suspect any abuse is taking place. The manager is aware of the POVA list but has not had to refer anyone to this. The Adult Protection policy is in line with the one adopted in the Local Authority area. As it was the time of the general election residents said that they had completed their postal votes. One man wanted to go to the local polling booth to register his vote and a senior care officer agreed to organise this for him. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 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 standard(s) 19, 20, 21, 23, 26 The home is clean and pleasant throughout offering a safe environment in which the residents live. Residents are able to have easy access to all parts of the home and the garden area. EVIDENCE: The home is designed to provide a safe and comfortable environment offering a number of small discreet sitting areas in addition to the larger lounges. There is a designated visitors room that can be used if the resident wishes to speak to someone in private or if they prefer to take their family to an area away from the other residents. The garden area is easily accessed from the home and has a locked gate to prevent anyone coming in to the area that should not be there. There are plenty of seats provided as well as table, chairs and umbrellas. There are bathrooms in the different areas of the home including ones with assisted bathing facilities as well as walk in showers. The toilets are near to SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 Page 16 the communal facilities to allow easy access for the residents. Notices are available to inform when they are in use to ensure the privacy of the residents. Individual bedrooms are comfortably furnished and residents can choose their own décor. The rooms are of a good size offering a safe and comfortable place for the resident to sit as well as sleep. Residents are encouraged to bring their own possessions with them and the inspector was able to see that most people had done this and personalised their rooms. The home was clean and tidy throughout with no offensive odours. Nothing was seen that could cause a hazard for the residents. A control of infection policy is in place and the home employs specific people to deal with the laundry. Residents spoken to all confirmed that they think their clothes are washed and ironed to a high standard. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 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 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, 29, 30 Residents are supported and protected by robust recruitment procedures. Staffing numbers and skills ensure that residents’ needs can be met. EVIDENCE: There were sufficient staff on duty at the time of the inspection and residents and the staff spoken to said this was the normal pattern. The staff rosters for past and future weeks were seen and these confirmed the numbers on duty. The manager said there had been problems in the past with staffing levels but these had now been dealt with. She is able to access extra staff if there is a situation requiring this. Most of the staff team have obtained Level 2 NVQ and some are now working on level 3. The manager plus two other senior staff members are NVQ assessors. Staff spoken to confirmed that they are able to access appropriate training without any problems. Individual training plans are in place as well as one for the home. Staff files were seen and these confirmed that the recruitment procedure was in line with equal opportunities. The manager said that two people short list applicants and then are involved in the interview process. POVA, CRB and Immigration checks are made on successful applicants in addition to two written references been obtained. People are not allowed to start working at the home until all these are in place. Induction training is given to all new staff. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 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 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, 32, 33, 35, 36, 38 The home is well managed and the manager is well able to discharge her responsibilities. She offers good leadership to the staff and ensures the residents are protected and cared for in a correct manner. EVIDENCE: The manager has over ten years experience in working with older people and shows a good understanding of their needs. She has applied to become the registered manager and is awaiting her Fit Persons interview with the Commission. Once she has been registered as the manager she intends to work towards the Registered Managers award NVQ level 4, already having Level 3. Staff and residents all confirmed that she is a very approachable and supportive person and one staff member described her as been “inspirational”. She is fairly new in post but already people have noticed improvements especially in staff morale. The manager herself said that she has begun to SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 Page 19 build relationships with the staff team and that they have begun to settle down. Most of the residents look after their own finances or their families help them to do so. The manager described the procedure that is in place where the home manages a resident’s financial affairs and this is in line with the standards. Residents’ financial records were examined and found to be in order. Staff supervision records were seen to be in place, and staff confirmed that sessions take place on a regular basis. A quality assurance system is in place and the recent questionnaires that had been completed by staff and residents were seen. As these are fairly recent the results have not yet been collated. The manager will examine the results and then put any action in place that is required to implement change or improve things. The manager showed a good understanding of Health and Safety and confirmed that staff have regular movement and handling training updates. Risk assessments are in place as required and the manager tries to ensure a hazard free zone at all times for both residents and staff. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 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 2 COMPLAINTS AND PROTECTION 3 3 3 x 3 x x 3 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 Standard No 16 17 18 Score 3 3 3 3 3 3 x 3 3 x 3 SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 Page 21 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 OP15 Regulation 16(g) & (i) Requirement The Registered Provider must provide suitable kitchen equipment and facilities for the preparation of food. (previous timescale of 01.01.05. not met) Timescale for action 31.05.05. 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 3 Good Practice Recommendations Written records of pre admission assessments should be made. SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley LEEDS LS 13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI SIEGEN MANOR CS0000033232.V231000.R01.doc Version 1.30 Page 23 - 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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