Inspection on 28/06/05 for The Manor

This inspection was carried out on 28th June 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 09/08/06

The Manor 05/12/05

The Manor 15/12/04

The Manor 05/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOMES FOR OLDER PEOPLE The Manor 75 Manor Road Selsey Chichester, West Sussex PO20 0SF Lead Inspector Annie Taggart Unannounced Tuesday 28 June 2005, 03:00pm th 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. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Manor Address 75 Manor Road, Selsey, Chichester, West Susssex, PO20 0SF 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) 01243 602828 Mrs Marcia Ann Manning-Smith Mrs Margaret Rose Jest Care Home 21 Category(ies) of PC Care Home only 21 registration, with number of places The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15/12/04 Brief Description of the Service: The Manor is a care home providing personal care and accommodation for twenty-one older people (over 65 years) who have learing disabilities. The home is located in a quiet residential area a short distance from the centre of Selsey village where shops and other facilities are available. Service user accommodation consists of thirteen single and four double rooms. An activities centre is situated in the grounds of the home and residents access this facility on a daily basis. The activities facility is seperately staffed. The home is owned by Mrs. M. Manning Smith. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out at 9.30am and lasted for six hours. During the course of the inspection time was spent with all of the residents living in the home and conversations were held with nine people. For other people who do not verbally communicate well time was spent looking at books and craft and observing interactions with staff. Five members of staff were spoken to and all gave very positive feedback about the home. The lunchtime meal was seen being prepared and served and people were observed attending the day service facility. Seven care plans and six staff files were read as was other documentation including health and safety files and maintenance records. A tour of all of the rooms in the home was undertaken and the proposed new building works were discussed with the registered provider Mrs. Manning Smith. Prior to the inspection the last two reports were read and any correspondence regarding the home seen. The residents and staff at the home were friendly and informative and the acting manager Mr. Manning Smith helped with the inspection. What the service does well: The home offers a friendly and homely environment for the people who live there. Residents said they were happy in the home and were complimentary about the staff. There is a wide variety of activities available and residents are able to access the day-care facility and have access to the wider community. Families, friends and advocates are made welcome at the home. Staff said that they are well supported by the acting manager and registered provider of the home and are offered supervision and training opportunities. There is a core staff group who have been at the home for a number of years and have built up good relationships with the people they support. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Medication procedures need to be reviewed to ensure the safety and wellbeing of residents. Recruitment procedures need to be reviewed to ensure that residents are protected by all new staff members having undergone a current Criminal Bureau Check. Consideration should be given to improving the care plans to include specific details of how staff members should support residents on a day-to-day basis. Consideration should be given to accessing training on the specific needs of people with a learning disability and also management of challenging behaviour. As good practice water temperatures should be recorded when they are tested. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 7 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 H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 2 3 4 5 6 Prospective residents and their families have sufficient information to make a choice about whether they wish to live in the home. Individual needs are assessed and visits to the home encouraged. EVIDENCE: A Statement of Purpose and Service User Guide are available and both have been recently reviewed and updated. The Service User Guide can be provided with Makaton symbols on request. A contract of the terms and conditions of occupancy is agreed with each resident or their representative. Prospective residents are assessed by the registered provider or the manager of the home prior to admission. Visits to the home and short stays are encouraged to assess the suitability of the home for each individual. One resident confirmed that he had visited the home with his family before moving in. The Manor does not provide intermediate care. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.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 11 The health and social care needs of Residents are identified and met through the care plan. There are risks to the safety and well being of residents by shortfalls in the medication systems. The people living in the home feel that they are treated with respect. EVIDENCE: There is a care plan in place for each person living in the home which sets out the health and social care needs of each resident. Plans are reviewed on a regular basis and daily updates on each person are discussed at the staff handover periods. There is evidence in the plans of input from other professionals such as district nurses, the community learning disability team and psychiatrists and each person is registered with their own doctor. One person is suffering from a pressure sore and is being treated by the district nurse. In conjunction with other professionals the staff at the home identifies when the facilities offered can no longer meet the needs of each person and one resident is waiting to be admitted into a nursing home. Although the care plans contained the basic information about each resident, consideration should be given to making the plans more “person centred” with The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 11 more information being available to inform staff on how to offer the support needed by individuals especially regarding the management of challenging behaviour. Staff treated residents in a kind and friendly way and offered personal care in a private and discreet manner. One resident said, “ I like it here, they are all decent people, the staff and the people who live here are much nicer than where I used to live and staff don’t moan and groan at me when I am a bit slow at doing things”. Many of the people living in the home have poor verbal communication skills but their body language was relaxed and comfortable with staff members. There are medication policies and procedures in place and all staff who administer medication receive accredited training. Risks to residents were identified with regard to gaps being found in the signing of medication recording sheets and the practice of using creams prescribed for one person for general use. A requirement has been made in respect of this Standard. If possible residents can stay in their own home until the end of their lives but this decision would be made in conjunction with the family and other health care professionals and would depend on the home having the facilities to meet the person’s needs. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.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 There is a variety of activities for the people who live in the home, families and friends are made welcome and a varied menu of fresh and wholesome food is available. EVIDENCE: Most people at the home attend the day service adjacent to the home where crafts and other activities are carried out. Most people seemed really happy to attend the facility but some chose to stay in the house. Two residents went out for coffee and shopping and said that they really enjoyed this. Staff members at the home take people out on a weekly basis for shopping trips and to visit café’s and the home hires a mini-bus on a regular basis to take people to swimming, the pub, pool or bowling. One resident was enjoying sitting on a garden swing chair in the sun and one person was very proud of the model planes he was making. The home has an “open” policy on visiting and relatives are invited to social events. For security reasons the large gates at the end of the drive are locked in the evenings so families and friends are asked to inform the staff prior to visiting late in the evening. Many of the people living in the home do not have families and are represented by advocates allocated in conjunction with the Social and Caring Services department. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 13 Menus showed that a variety of wholesome food is available and diabetic and liquefied meals are catered for. Residents were seen enjoying lunch, which is the main meal of the day and the meal including two fresh vegetables and fresh strawberries and cream. The people living in the home said that they enjoyed the food provided and one person said they were looking forward to their birthday party where a diabetic cake was being provided. One person who became distressed and said that they did not wish to remain in the dining room was supported by a member of staff to have their meal in the lounge area. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.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 18 Residents and their families can be confident that their complaints will be taken seriously and staffare aware of policies and procedures in respect of protecting residents form abuse. EVIDENCE: There have been no complaints recorded in the last year but residents said that they would speak to a staff member if they were unhappy. The acting manager and staff said that they do respond to any grumbles made by residents and recordings of the outcomes were seen in the daily handover book. A requirement for staff to attend training in the protection of vulnerable adult has been met and all of the staff members spoken to show an awareness of the procedures to follow should they suspect an abuse had taken place. The whistle blowing policy has been recently reviewed and updated and has been signed by all staff at the home. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.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 22 23 24 25 26 The home offers a clean and homely environment for the people who live there. Some of the facilities are in need of updating and plans are in place to achieve this. EVIDENCE: The home has a large lounge and conservatory area and a light and airy dining room. There is a garden available where a gazebo has been fitted to allow residents to safely sit out in the hot weather. There have been some improvements made to the environment since the last inspection and the hallway and stairs are currently being redecorated. Residents said they were happy with their bedrooms which have all been personalised with people’s own belongings, photographs and craft work. Residents have a choice of whether to have a lock fitted to their bedroom doors and this is recorded in the care plan. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 16 There are sufficient baths and toilet facilities available and some improvements have been made to décor and flooring. There are assisted baths available and handrails and grab rails are fitted as necessary. Some bedrooms have pressure relieving mattresses and cushions and the use of this equipment is overseen by the district nurses. New laundry equipment has been fitted to meet the standard required in respect of infection control and health and safety information is posted to inform staff. Planning permission has been granted for major building works to be carried out at the home in order to upgrade all facilities to meet the current National Minimum Standards. Plans include all bedrooms being upgraded with en-suite bathrooms, modernisation and extension of the laundry and upgrading of the day-care facility. It is intended that an assessment is carried out on the newbuild by an occupational therapist to ensure it meets the required standards. The registered provider, acting manager and staff at the home are working with the architect to try to minimise disruption to the people who live in the home during the changes. It is hoped that building will commence within the current year. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.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 28 29 30 There are sufficient numbers of staff available to meet the assessed needs of the current residents in the home. Training is available to ensure staff members are competent in their role. To ensure the safety of residents current Criminal Bureau Checks should be carried out for all new staff. EVIDENCE: There were four care staff on the early shift plus the acting manager and two ancillary staff. The late shift also had four staff available. A member of staff phoned in sick and staff on duty offered to stay on to cover the gap. The number of staff on duty matched the home’s rota. The day-service is separately staffed. Many of the staff have worked at the home for a number of years and have built up good relationships with the people who live there. Staff members made very positive comments about the induction and training available in the home and training records showed attendance at a number of courses including mandatory training, epilepsy, continence management, diabetes and infection control. Several of the staff members working in the home have achieved NVQ 2 or above and others are currently undertaking the award. Staff dealt with a resident who was distressed in an appropriate manner but there was no record of staff having received relevant training. Consideration should be given to staff receiving specific training in learning disability awareness and the management of challenging behaviour, for new staff this could be achieved by the use of the Learning Disability Awards Framework induction programme. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 18 The home carries out good recruitment and selection procedures but two new staff recently recruited to the home had not been referred for new criminal Bureau Checks before taking up employment. A requirement has been made in respect of this Standard. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 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 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 36 37 38 The home is currently managed by an acting manager who discharges his responsibilities in a capable manner. The policies, procedures and working practices in the home promote the safety and wellbeing of the people who live there. EVIDENCE: The home is currently being managed by acting manager Mr. Mathew Manning Smith who has applied to the Commission to be registered. Mr. Smith has experience of working with people with a learning disability and is currently undertaking NVQ 4 and the Registered Managers Award. Staff members at the home spoke very highly of Mr. Smith’s management style and said that he was accessible and open to suggestions. Staff also said that many improvements to the home had been made since Mr. Smith had taken up post. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 20 Staff members confirmed that they received supervision and sessions are recorded. Mr. Smith is currently reviewing the system to identify training needs and implement a record of achievement for each person. All of the policies and procedures in the home have been recently updated and at the suggestion of the deputy manager a “policy of the month” has been implemented where each staff member reads and signs a designated policy which is then discussed at handover or the team meeting. Records at the home are in good order and to ensure the safety of residents and staff at the home a new fire alarm system has been installed. Fire training is up to date and fire drills are recorded. Radiators in the home are covered and water outlets have thermostatic control valves. The handyman at the home said that he tests the water temperatures weekly but as good practice this should be recorded. Mr. Smith has recently sent out quality assurance questionnaires to families, friends and other professional people involved with the home. When all of the replies have been received Mr. Smith intends to collate the responses and publish the findings. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 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 x 3 3 3 3 x x 3 3 3 The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 22 No 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 9 Regulation 13 Requirement Timescale for action 15th July 2005 2. 29 19 Prescribed medications including creams must not be used for anyone other then the person for whom they are prescribed. Medication recording sheets must be kept in good order. All new staff must have a current 30th July Criminal Records Bureau check 2005 before commencing employment. 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. 2. 3. Refer to Standard 7 30 38 Good Practice Recommendations Consideration should be given to improving care plans to include day-to-day support guidelines for staff to follow. Consideration should be given to accessing induction and training specific in the needs of people with a learning disability. As good practice when water temperatures are tested the outcomes should be recorded. The Manor H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY 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 H60-H11 S14783 The Manor V232205 280605 Stage 4.doc Version 1.30 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. 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