Inspection on 11/06/07 for The Manor

This inspection was carried out on 11th June 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

The Manor 13/12/05

The Manor 19/09/05

The Manor 01/03/05

The Manor 21/09/04

The Manor 26/01/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE The Manor The Green Scotter Gainsborough Lincs DN21 3UD Lead Inspector Ken Hague Key Unannounced Inspection 08:00 11th June 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 The Manor DS0000002451.V330250.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. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor Address The Green Scotter Gainsborough Lincs DN21 3UD 01724 764884 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) Mrs Susan Murray Mr John Russell Murray Mrs Susan Murray Mr John Russell Murray Care Home 25 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (24) The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2005 Brief Description of the Service: The home is owned and managed by the proprietors, Mr & Mrs Murray and their daughter as a ‘family’ business. The Manor is an adapted grade two-listed property. The home is set in large gardens opposite the church in the village of Scotter. The village green at the front of the building is also owned by the home. Situated in the middle of the village, the home is close to local amenities, which include shops, post office and local public houses. The home is registered for twenty-four older persons over the age of sixty-five years and one mental disorder, excluding learning disability or dementia. Accommodation is provided in both single and shared rooms. All rooms have en-suite toilet and wash hand basin facilities, with one room also having a bath. Rooms are located on ground and first floors. There is a passenger lift provided for residents who are unable to use the stairs. The lounges and dining room areas are located on the ground floor. Car parking is provided to the front and to the side of the home and there are external ramps to two of the entrances to the home. The home charges £394 to £425 per week. The care home has a statement of purpose and service users guide which sets out the resources of the home and the facilities offered to residents These documents are shown to all visitors who are considering coming to stay in the home. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6.0 hours. The registered manager and deputy manager were provided with feedback at the end of the inspection. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them and the staff, and where more appropriate observation of interaction between staff and residents and related care practices. A sample of care records was inspected. Two members of staff were interviewed and the opinions of five residents were sought. A Pre-inspection questionnaire was supplied prior to the site visit being made. In addition 1 “have your say” documents completed by a resident was sent to the Commission for Social Care Inspection. This document asks 12 questions and invited residents to make comments regarding the care they receive from the home. The feedback and comments from the ”Have your say document” is included within this inspection report . A visitor was spoken to during the site visit. Their comments and opinions are reflected within this report. What the service does well: The home provides a comfortable, safe and homely environment for people to live in. It is very well managed and organised. Residents have detailed care plans, which enables staff to know how residents needs are to be met. Regular residents meetings and care reviews are held where residents comment on the services provided by the home. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 6 Staff are well trained and supported by the registered manager and have a sound knowledge of residents needs. The staff team work well together and have established a good working relationship with the community health care teams and local GPs. 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. The summary of this inspection report can be made available in other formats on request. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 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 The Manor DS0000002451.V330250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: 3 individual residents files were examined as part of the case tracking process. They all contained a full assessment including a risk assessment for each individual resident. The assessment set out care needs social needs and health needs. Residents stated that they have been involved in the initial assessment with their families. The registered manager confirmed this statement to be correct. Two members of staff stated assessments are carried out prior to admissions by the registered manager. Three residents confirmed that they had received an assessments prior to being admitted The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 9 The registered manager stated that a dedicated intermediete care service is not provided. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9, 10 &11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans identify all areas of need and provide detailed care instructions which enables staff to provide appropriate care and meet residents needs. EVIDENCE: The care records of three residents were inspected in detail and discussed with the deputy manager and staff. All three individual files contained a full care plan using the information gathered at an assessment carried out prior to admission. The care plans contain details of the input from other professionals such as GPs doctors and social workers. The residents weight is recorded and monitored with their permision.There was evidence of involvement of family and the resident in the preparation of the individual care plans. A relative spoken to during the site visit confirmed she had been involved in the writing of care plans for her relative. Care plans set out health care, social care needs and how these were to met by the resources of the care home. There was evidence on files of dental appointments, Eye care, and chiropody. Residents confirmed they chose which professionals they use to provide their health care services. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 11 The care plans were personalised and individualised treating each resident very much as an individual and balanced out the identification of needs against the wishes and choices of the resident. Medication needs, dietary needs, and activities were all recorded within care plans. Not all care records were consistently signed and dated the home is to address this issue. Staff have been trained by outside agencies in the administration and storage of medication. Medication records had been completed in accordance with the national guidelines. Drugs are being stored correctly. Staff and the registered manager stated that residents can self medicate if they request to do so and a risk assessment confirmed that this would be safe practice. Information from the” have your say document” completed by a resident and discussion with residents and staff provided evidence that the rights of residents are respected and their privacy and dignity is upheld. Observations on the day of the site visit supported this judgement A resident stated in discussions “staff are sensertive and provide care in a caring way. they always knock at my door and ask permision to enter my room. I feel safe when thsy are helping me. Care records demonstrated that each resident has been asked how their care should be provided. The action to be taken in the event of the death of a residents was found to be recorded on their individual care plans. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 & 15Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities is provided for residents, which meets their needs and wishes. A healthy balanced diet that is based on the likes and dislikes of residents is provided. Staff support residents to be independent. EVIDENCE: The registered manager listed, in the Pre inspection questionnaire, a number of activities offered to residents including opportunities to take part in events in the community. Staff and residents confirm these activities do take place during the site visit. The home provides religious services for residents who wish to take part and pursue their individual religious beliefs. Two residents stated that they attended a local club in the village and often go shopinging togeather in Scotter. Staff and the registered manager stated that the home takes a number of residents out to lunch at the local pub in the village on a regular basis. Residents spoken to during the site visit said that activities are provided some of which they choose take part in. A number of residents had decided to watch tennis together on the day of the site visit. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 13 Staff stated that the care home has a visiting policy which is flexible to meet the choices and wishes of the residents. A visitor was spoken to during athe Inspectors visit. They confirmed that they were made welcome when they visit the care home and were highly satisfied with the care being provided by the home. They have two relatives who are residents of the care home. The choices and wishes of residents was found to be recorded on their individual files. Residents choose which chiropodist hairdressers and optician they use. The registered manager sent a copy of the menu prior to the site visit this demonstrated that choice was being offered. The inspector observed staff asking residents at lunchtime what choice of the meal they required. The dietary needs of individual residents, was found recorded on their care plan. Positive comments were made by residents in respect of the menu. A residents stated the food is excellent at this home there is plenty of choice. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home listens to resident’s concerns and acts on them. There are procedures in place to protect residents from any possible abuse. Staff have received appropriate training to protect residents from being harmed. EVIDENCE: There are policies in place for safeguarding adults, whistle blowing and risk management. A copy of the complaints procedure is displayed in the reception area of the home, and is also found in the service user guide. Staff said that they receive training in regard to safeguarding adults and training records confirmed this. Staff were aware of the Lincolnshire county council adult abuse procedure and knew how to report any suspicion of abuse. Records show that there have been no formal complaints or safeguarding adult referrals since the last inspection. Residents stated that they know how to make a complaint, and that when they talk to staff they always help to put things right. One resident said that they could talk to the registered manager if they’re not happy with anything. Risk assessments are available in individual care files for needs such as falls, moving and handling, self-medication and the use of bed rails. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean and comfortable home. There are appropriate aids and adaptations provided in the home to maintain residents’ independence. EVIDENCE: The home is well maintained, decorated to a high standard and clean throughout. The area outside the home is also well maintained and safe. Residents are encouraged to bring possessions into their rooms and to make them homely. Each room is individually furnished, and residents stated that they were fully supported to use their rooms safely and in the way they wished. There are enough bathrooms and toilets to meet the needs of the residents and appropriately serviced equipment is in place to support resident’s physical needs as appropriate. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 16 The staff interviewed confirmed that fire alarms are tested weekly, and were able to describe the appropriate action they would take in order to maintain residents and staff safety in the event of a fire. All areas of the home were clean and smelt fresh. Discussions with staff and the deputy manager identified no health or safety or infection control policy problems within the care home. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by well-trained staff. The recruitment processes is robust and protects residents. EVIDENCE: Staff stated that the staffing rota is always followed ensuring sufficient staff are always on duty to meet residents needs. Residents spoken to stated that they do not have to wait long for assistance staff respond very quickly to requests for help. Two residents spoken two stated the staff here are excellent. The home had a calm atmosphere during the site visit. Residents needs were observed to be met quickly and sensitively by members of staff. Four residents stated that they feel safe living in the care home. Staff stated they felt residents were in safe hands at all times. Care records demonstrated that staff are instructed how to provided services safely. The registered manager stated that recruitment files contain applications forms, interview records, criminal records bureau checks, references and terms The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 18 of conditions. This standard has been consistently met over the last three inspections. Staff turn over is low and no new staff have been employed since the last inspection There is a comprehensive induction programme available for new staff and completed records were seen. Records show that staff have undertaken training in subjects such as safeguarding adults, fire safety and first aid. There is also evidence that staff are either undertaking or have completed NVQ training. During discussions staff said that they have good access to training that relates to the needs of residents. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 19 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): Standards 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is leadership and guidance for staff, which ensures that services are provided in a safe manner. The home’s health and safety policy and infection control policy is being followed which maintains a safe environment. EVIDENCE: A registered manager is in post supported by a deputy manager. Staff stated that she is approachable, residents described her as a very good manager. Residents stated that they feel the home is run in their best interest. Discussions with staff and the deputy manager on the day the site visit and observations provided evidence that resident’s needs are seen as paramount. There are financial procedures in place to ensure that residents financial interested are safeguarded and protected. The care home only holds personal The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 20 allowance money for to residents. This money is entered into financial records and is issued on the signature of two memebrs of staff. Staff stated that supervision are being carried out which are and linked to appraisals, Staff confirmed the home’s manager does encourage them to develop their individual skills. Staff said that the registered manager gives them very good support and makes sure that they have the resources to do their jobs well. A discussion with a visiting relative provided evidence that they were very satisfied with the care and support provided by the home. The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 21 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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 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 The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 22 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 The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 The Manor DS0000002451.V330250.R01.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!