Inspection on 19/09/05 for The Manor

This inspection was carried out on 19th September 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 13/12/05

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 Ann Day Unannounced Inspection 19th September 2005 11.45a 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.V250812.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.V250812.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.V250812.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 01.03.05 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 service users 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.V250812.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day in September 2005 The inspection incorporated an investigation under local adult protection procedures into concerns that had been raised. At the time of the inspection the home was accommodating 12 residents. Case tracking was employed as an inspection tool, which involves following the experience of a sample of service users and assessing the service they receive. All service users spoken to during the inspection were complementary about the service they receive. The manager and members of staff were interviewed, and documentation was examined. What the service does well: What has improved since the last inspection? What they could do better: Improvements should be made to current use of communication/message books in the home. The Manor DS0000002451.V250812.R01.S.doc Version 5.0 Page 6 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.V250812.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.V250812.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 Prospective service users are assessed and assured that their needs can be met before they are admitted. EVIDENCE: All care records examined contained a pre admission assessment; the manager and staff confirmed, the manger or her deputy, assess prospective service users before they are admitted. The home does not provide intermediate care. The Manor DS0000002451.V250812.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): 7,8,9,10,11 Service users health, personal and social care needs are set out in an individual care plan and their health care needs are fully met. Service users are protected by the home’s policies and procedures for dealing with medicines. Services feel they are treated with respect and their right to privacy is upheld; and they can be assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. EVIDENCE: All care records examined included detailed care plans, which had been regularly evaluated and reviewed, individual risk assessments and detailed the input of other professionals. As part of an investigation under local adult protection procedures examination of the care records of current and past residents was undertaken. Care records examined evidenced the close attention paid to weight monitoring, fluid in take and output; safe moving and handling; pressure area care; medication administration; and the regular input of general practitioners, district nurses and community psychiatric nurses as appropriate. There was evidence that service users are admitted to hospital if their condition warrants admission. The Manor DS0000002451.V250812.R01.S.doc Version 5.0 Page 10 The home has policies and procedures in place for the safe administration, storage and disposal of medication. Medication was administered and recorded accurately during the visit. Care records of current and past residents evidenced safe medication administration and recording. General practitioner’s reviews of prescribed medication, was well-documented. Members of staff were observed delivering personal care with sensitivity and with mutual positive regard, they were observed knocking on doors and awaiting an invitation before entering. Service users confirmed that this was their home and they were treated well. Members of staff said, “ treated as I would like my mum treated, “I am really happy to do a good job” “The ladies come first” “Wouldn’t stay and work here, if there was anything wrong”. The home has policies and procedures for the care of the dead and the dying; care records evidenced the frequent and extended visiting of relatives of the very ill. Service users last wishes are recorded and the manager and members of staff confirmed that either the manager or a member of staff ensures that a very ill service user is not left alone; care records confirmed this. The Manor DS0000002451.V250812.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): 12,13,14,15 Service users are offered a range of activities, and contact with family/ friends/ representatives is encouraged and maintained. Service users exercise choice and control over their lives; and the home provides service users with a wholesome, appealing balanced diet. EVIDENCE: The home provides service users with daily newspapers and magazines. Members of staff said, “We do what they like to do, love old songs, one lady plays the piano, do small things every day”; ”some residents went to the village concert, they often sit out in the garden”. “ They are all individuals” Some of the residents attend church which is next door and a clergyman visit the home on a regular basis. Members of staff said, “there are loads of visitors, majority in the afternoon, a lot over the weekend”, this was confirmed by the home’s “Visitors Book” which documented visitors during the day, evenings and weekends. “They get up and go to bed when they want to, some are up and chatting when the night staff come on at 10pm, and there is no special time to get up, “ The Manor DS0000002451.V250812.R01.S.doc Version 5.0 Page 12 said members of staff. One service user who was in bed during the visit said, “I please myself, dear”. Care records of past residents included the recording of a service user choosing to rise early and a service user waking early. Written instructions left for staff, by the manager emphasised the need to encourage choice, privacy and individual preferences. The meal provided at lunchtime, was appealing hot and well enjoyed by the residents. Members of staff said, “Plenty of choice very good food, staff can have a meal if they want, we ask residents what they want”. Menu choices were recorded in the home’s diary. Two residents are provided with diabetic diets, which include fruit as an alternative to home made puddings. The home has sought advise from the general practitioner with regard to their diet. The Manor DS0000002451.V250812.R01.S.doc Version 5.0 Page 13 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): 16,18 Service users and their relatives can be confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Service users spoken to said that they would tell members of staff if they were unhappy. Members of staff interviewed were clear about their responsibilities regarding bringing concerns to the manager’s attention. The home has a comprehensive Complaints policy and procedures, which were available for examination. The Commission has received one complaint about the home since the last inspection, the manager cooperated positively with the complaint investigation; the complaint was not upheld. The home has an adult protection policy and procedures in place; and a copy of the current guidance from the local authority. Members of staff confirmed that they have received specific training and would have no hesitation in reporting any incident. The manager and members of staff, cooperated positively with the investigation under adult protection protocols, the allegations were unsubstantiated. The Manor DS0000002451.V250812.R01.S.doc Version 5.0 Page 14 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): 19,22, 26 Service users live in a safe, clean, odour free, well-maintained environment; and they have the specialist equipment they require. EVIDENCE: The home has corridor rails, mobility equipment, a passenger lift and a hoist to promote service users independence, all servicing documentation and certification was in order and available for examination. The home was clean, tidy, well decorated, odour free and well maintained. Currently care staff carry out domestic duties as part of their key worker role. Members of staff said, “Both cleaners have left, as a key worker I help keep the resident’s room nice, its not a problem, the bathrooms are done every day, Mrs Murray is very particular, we are very proud of the home”. “Its all part of care, room clean, clothes tidy, if you see a mess, clean it up; night staff clean communal areas, it’s not a problem at all, ladies come first, tidying comes after” The Manor DS0000002451.V250812.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 Service users needs are met by sufficient numbers of skilled and competent staff. Service users are supported and protected by the home’s recruitment policies and practices. EVIDENCE: Service users expressed no concerns about staffing numbers or the care the staff provided for them in the home. Members of staff said that in their opinion there are always sufficient numbers of staff on duty. Care tasks and the cleaning regime are adequately addressed in the numbers of staff on duty. This was confirmed by examination of the staff rosters and speaking to the manager and her deputy. The home has robust recruitment policies and procedures, which were available for examination. Staff files are in order; and included, application forms, two written references, Criminal Records Bureau and POVA checks. Members of staff interviewed confirmed that they had completed an induction, and one had completed NVQ Level2. Members of staff said that they were never asked to undertake tasks that they were not skilled to complete. Staff files included individual training records and copies of training certificates. The Manor DS0000002451.V250812.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): 32,35, Service users benefit from the ethos, leadership and management approach of the home and their financial interests are safeguarded. EVIDENCE: All service users consulted were happy with the care provided and enjoyed living in the home. Members of staff said that they held the manager in high regard “Couldn’t find a better boss”, “No concerns about the care given to residents, Mrs Murray would take action if there was a problem”. Members of staff described the manager and her deputy as “very approachable”. The current deputy manager is sourcing the Registered Managers Award and will be starting in the near future, on target to complete the award by 2007. She has applied to the Commission to be registered as the manager of the home. The Manor DS0000002451.V250812.R01.S.doc Version 5.0 Page 17 Currently the home uses a communication/message book, which they are not required to keep; the manager and her deputy were advised to revisit the content, to keep the instructions to staff brief, not to duplicate care record entries and to make better use of staff meetings, when wishing to emphasise an issue to members of staff. The home does not hold any of the resident’s monies, any shopping for residents is receipted and individual invoices are raised. Residents have locked facilities in their rooms for the safe storage of monies and valuables. The Manor DS0000002451.V250812.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 X X 3 X X X 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 3 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 X 3 X X 3 X X X The Manor DS0000002451.V250812.R01.S.doc Version 5.0 Page 19 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. 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.V250812.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. 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