Inspection on 13/12/05 for The Manor

This inspection was carried out on 13th December 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

The Manor 11/06/07

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 Mr Ken Hague Unannounced Inspection 13th December 2005 09:00 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.V272372.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. The Manor DS0000002451.V272372.R01.S.doc Version 5.0 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 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.V272372.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19/09/05 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 Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 8am and 12.30pm. The main method of inspection used is called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. A tour of the premises was conducted and care records were inspected. Two members of staff and three service users were interviewed. What the service does well: What has improved since the last inspection? What they could do better: The home has been requested to review records relating to the menu for residents. This is to ensure that there is evidence of choice been offered. Night care records require reviewing to ensure that they demonstrate the time The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 6 staff check residents. These records must be dated and signed by the member of staff. 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 Manor DS0000002451.V272372.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 The Manor DS0000002451.V272372.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): 1,2,3 & 6 There are satisfactory procedures for the introduction and assessment of people to the service, ensuring that care needs are met. Residents are happy with the care provided. EVIDENCE: The home has a statement of purpose and service user guide which enables residents to make an informed choice whether their needs can be met by the resources of the care home. These documents were discussed as part of the inspection. The registered manager stated that all residents are given a copy of the terms and conditions for their stay at the home. Residents confirmed that they had a copy of this document. The inspection of the care records for residents being case tracked provided evidence that full assessments had been carried out prior to them coming to stay at the care home. The registered manager stated all new residents are encouraged to visit the home prior to making any decision to stay there. The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 9 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 & 10 Care plans contain comprehensive information, which identify the care needs and personal preferences of the residents. Risk assessments are of a good quality, providing management strategies that enable residents to be as independent as possible. EVIDENCE: The quality of care records have improved since the last inspection. The home has reviewed its care records, particularly care plans and risk assessments. These now are very detailed setting out the wishes and choices of residents their social and health care needs. Care plans provided evidence of involvement of community health services district nurses, chiropodists, and opticians. The care plans were easy to read enabling new staff to understand the care needs of individual residents. In the case of the three residents being case tracked where a risk was identified the management of that risk was recorded. The wishes and choices of individual residents in relation to their personal life are recorded on their care plans. All files inspected were tidy with information been filed in a consistent manner. Staff stated the care records were working documents easy to use and helpful to all staff. The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 10 In the formal interviews staff consistently referred to the rights of residents. They gave examples of how they ensured that the dignity and privacy of individual residents was maintained while providing bathing. staff were observed to speak to residents in a sensitive, respectful way while assisting them with personal care. Staff were seen to always knock at doors before entering bedrooms. The registered manager asked the Inspector to leave the care home without walking through the dining area where residents were eating. This demonstrated that she was ensuring the privacy of the residents was respected and ensuring that the inspection process did not intrude unnecessarily into the daily life of the residents. The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 11 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 The home provides a range of leisure and social activities. Contact with relatives and friends is encouraged. EVIDENCE: The home provides a number of activities, board games are provided and local entertainers visit the home. In the last month a local choir visited the home and bell ringers from a local church. One resident stated that she had been allowed to bring her home piano into the care home. She was observed to play this several times during the period the Inspector was in the home. The care records of one resident stated that she went into the local community to visit a friend or carry out some shopping. This resident confirmed this statement to be accurate. Residents spoken to during this visit confirmed their satisfaction with the activities offered by the home. The register manager stated that the local minister visits the home on a monthly basis to hold a local service. Staff and residents confirmed these services do take place. The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 12 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 The home has robust procedures for handling allegations of adult abuse. Staff were clear on the action to take in the event of this occurring. The home has a complaints procedure which is displayed in the home and is known to staff and service users. Service users are able to raise any complaints or concerns through this procedure or resident’s meetings. EVIDENCE: There is information for residents and their relatives about how to make a complaint displayed in the entrance hallway. Residents said they felt confident that they could raise any concerns with the management of the home. A copy of the Lincolnshire Adult Protection Committee procedures was in place, enabling staff to follow the correct local procedures. Two members of staff stated “we know where this policy is kept in the office and have read this document”. Staff were able to describe how they would respond to allegations made by residents, in order to keep them safe. Residents and staff stated that they felt safe in the home. The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 13 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): 19,26 The home is well maintained and decorated. It is homely and comfortable, odour free, and was found to be cleaned to a high standard throughout. There are appropriate aids and adaptations provided in the home to maintain residents’ independence. EVIDENCE: A tour was made of the care home. All areas were very clean and smelt fresh. There was evidence of ongoing maintenance, all areas have been decorated to a high standard. Fixture and fittings were of a domestic nature and furniture was arranged in a sensitive manner to present a homely and domestic environment. There were extensive Christmas decorations throughout the home. The registered manager stated that great effort was made by all staff to make the environment as near to a domestic home as possible. Residents spoken to confirmed their total satisfaction with the environment of the care home. The bedrooms seen during this visit had furniture and fittings which The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 14 met the National Minimum Standards and contained personal possessions belonging to individual residents. The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 & 30 The home ensures that appropriate staff are recruited and employed by the home. There are always sufficient numbers and skill mix of staff on duty. Staff are trained to ensure they are competent to carry out their employed tasks. EVIDENCE: The registered manager stated that no new members of staff had been recruited since the last inspection. She confirmed the recruitment policy of the home which meets the National Minimum Standards is being followed. The two members of staff interviewed confirmed that in their opinion there were always sufficient numbers of staff on duty to meet the needs of residents. A resident stated “staff can not do enough for you”. All the residents spoken to felt there was sufficient staff on duty to meet their needs. The staff confirmed that staffing levels are not reduced below that stated on the homes staffing rota. The registered manager stated additional staff are employed on shifts where any additional task such as taking a resident to hospital have been identified. The home has a staff training programme in place using internal trainers and external consultants. The staff interviewed confirmed training including specialised training is being offered to staff at the home. The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 &38 The home has an experienced and supportive registered manager who has worked in the provision of residential care for many years. The health and safety policy of the home is being followed. Staff are not however being provided with supervisions and appraisals as required by the Care Home Regulations. Staff responses to formal questions provide evidence that they considered the choices wishes and dignity of residents when providing care. EVIDENCE: The home as a registered manager who has worked in the field of providing community care for many years. A resident stated “she is very kind and approachable.” a member of staff stated “I like my job very much we are very well supported by the manager and her daughter.” The two members of staff interviewed stated that “staff morale is high and good teamwork operates within the care home”. The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 17 There were no health and safety issues identified during this inspection. Residents stated their satisfaction with the attitude of all staff who they describe as caring helpful people. Staff stated that supervision and appraisals were not being provided in accordance with the National Minimum Standards. The registered manager confirmed this information to be correct. The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 18 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 3 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 x x x x 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 3 x 3 x 3 2 x x The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP36 Regulation 18-2 Requirement The registered person must provide staff with supervision in accordance with the care home regulations Timescale for action 28/04/06 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.V272372.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 The Manor DS0000002451.V272372.R01.S.doc Version 5.0 Page 21 - 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!