Inspection on 05/12/05 for The Manor

This inspection was carried out on 5th 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 09/08/06

The Manor 28/06/05

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 Inspection 5th December 2005 03:00 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 DS0000014783.V269374.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 DS0000014783.V269374.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Manor Address 75 Manor Road Selsey Chichester West Sussex PO20 0SF 01243 602828 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 Marcia Ann Manning-Smith Mr Matthew Manning-Smith Care Home 21 Category(ies) of Learning disability (21), Learning disability over registration, with number 65 years of age (21) of places The Manor DS0000014783.V269374.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to 21 male and/or female service users in the category Learning Disability over 65 years may be admitted/ accommodated. Up to 21 male and/or female services users in the category Learning Disability aged from 50 years may be admitted/ accommodated. A total of 21 services users may be accommodated. Date of last inspection 28th June 2005 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 learning 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 separately staffed. Mrs. M. Manning Smith owns the home. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit was carried out at 9.30am and lasted for 5.5 hours, which covered the early and late shift in the home. During the visit the inspector spent time with all of the residents in the home joining them at the day- care facility and chatting about Christmas preparations. Many of the people in the home have poor verbal communication and time was spent observing staff interactions and looking at craftwork and activities with people. A tour of the building was undertaken which included all of the communal areas and private bedrooms and the inspector saw lunch being prepared and served. The inspector spoke to five staff members and saw six care plans and six staff recruitment and training files. Any issues arising from tracking these documents were discussed with the manager. Records for the running of the business were also seen which included health and safety records and incident/accident forms. At the present time there are major building works underway which will greatly improve the facilities offered at the home. The manager Mr. Manning-Smith was present at the home and assisted with the visit. What the service does well: What has improved since the last inspection? The home now has a new registered manager in post, who is working hard to improve the facilities in the home. There is an extensive building programme underway to improve the physical environment and extend communal areas and other existing rooms have been re-decorated and improved. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 Page 6 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 Manor DS0000014783.V269374.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 DS0000014783.V269374.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): 123456 The Statement of Purpose and Service User Guide will be updated when the building works are completed to ensure prospective residents have current information about the home. Needs are assessed and visits to the home prior to moving in are encouraged. EVIDENCE: There is a Statement of Purpose and Service User Guide available, which sets out the facilities available in the home. The documents need to be revised with regards to the change of manager and the new facilities available. Mr. Manning Smith said that he is working on updating the documents for when the building work is completed and is also going to produce accessible formats. The manager of the home assesses prospective residents in their current accommodation and a pre-admission assessment is carried out in conjunction with the care manager and other significant people involved with the person’s care. The pre-admission assessment was seen for one resident who recently came to live in the home and the document contained information on all of the health The Manor DS0000014783.V269374.R01.S.doc Version 5.0 Page 9 and social care needs of the person. The Caring and Social Services also produce an assessment and plan of care needed. Visits to the home are encouraged over a period of time to allow people to meet other residents to feel secure about the move. The new resident was able to confirm that they had visited the home prior to moving in. All new residents receive a contract setting out the terms and conditions of residency and the resident or their representative signs the document. The Manor does not provide intermediate care. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 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 the following standard(s): 7 8 9 10 11 The health and social care needs of each resident is recorded in a plan of care and people are treated with respect. Wherever possible people stay in the home until the end of their lives. Medication procedures need to be reviewed. EVIDENCE: Each resident has a plan of care which sets out their health and social care needs and the documents are regularly reviewed and updated. The manager of the home is presently reviewing and updating the format used in order to provide the staff team with more concise and easily accessed information. Risks are assessed using a scaled measure but would benefit from risk management plans being developed and recorded for the identified risks. There is evidence of input from a variety of healthcare professionals including district nurses, local doctors, the community learning disability team and speech and language therapists. During the visit two people were unwell and in bed and daily recording had been updated to inform staff of their needs. A quality assurance feedback form was seen from the district nurse team, which made very positive comments about the care provided in the home. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 Page 11 The home has an agreement in place with a local pharmacy and all staff members who administer medication receive accredited training. Medication was appropriately stored and the administration records were in good order. However there was an error in the number held of one medication and a requirement has been made in respect of this Standard. The home has policies and procedures in place with regards to the care of people at the end of their life. Wherever possible people can stay in the home at this time and the decision about whether the home can meet their needs is decided with the care manager and other healthcare professionals. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 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 the following standard(s): 12 13 14 15 The home meets the lifestyle choices of the people it supports and families and friends are made welcome. There is a variety of wholesome and attractive food available and residents are encouraged to be as independent as possible. EVIDENCE: The home has a separate day-care facility next to the main house which most people access each day. Residents also said that they enjoyed going to the cinema, clubs, pubs and out for meals and some people said that they had enjoyed going to a pantomime. Outings are arranged for shopping and days out and entertainers also visit the home. People said they were really looking to a party due later in the week and also the local Lions Club, who bring their Christmas sleigh and carol singers up to the home each year to entertain people. A local church provides a religious service in the home for those people who wish to attend. Private bedrooms also showed evidence of people being encouraged and supported to follow their hobbies and interests. Residents also said that they like caring for the two guinea pigs, which are a new addition to the home. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 Page 13 Visitors are made welcome and contact with family and friends is encouraged and supported. Menus show that there is a variety of wholesome home cooked food at the home and alternatives are also available. The home has taken advice from a Nutritionalist and the Speech and Language Therapist on dealing with people who need special diets and pureed meals. The pureed meals served during the visit were attractively presented and served to people who needed support in a respectful and unhurried manner. Residents said that the food was “really good” and that they enjoyed it. Each person’s care plan includes a nutritional assessment and weights are recorded monthly. The cook said that she also provides special cakes and meals for people with diabetes and other medical conditions. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 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 the following standard(s): 16 18 Residents and their families can be confident that their complaints and concerns will be listened to and acted upon and there are procedures in place to ensure that people are protected for the risk of abuse. EVIDENCE: The home has a complaint procedure a copy of which is included in the Statement of Purpose and Service User Guide. There have been no complaints recorded since the last visit but staff said that they try to act on any grumbles from residents as soon as possible. There is a Whistle Blowing policy in place and the staff team access training in the protection of vulnerable adults from abuse. All of the staff members spoke to were aware of their responsibilities should they suspect an abuse had taken place. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 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 the following standard(s): 19 20 21 22 23 24 25 26 There are major building works underway in order to update and improve the facilities available in the home. Private bedrooms have been personalised and the home is well maintained and clean. EVIDENCE: The home is at the present time having seven new bedrooms with en-suite facilities built to the front of the building. The plan is then to move the people from rooms that need updating into the new rooms and the old bedrooms will then be re-arranged to provide more communal facilities. All bedrooms in the home should then be single rooms with people only sharing if they wish to do so. The building works are well protected in order to keep residents safe and to minimise disruption to daily life. There are sufficient toilets and bathrooms available including hoist- assisted baths and a shower and the home has handrails and grab rails in place to aid mobility. A new ramp has also been built to make access easier to the home. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 Page 16 Private bedrooms are comfortable and have been personalised by the people living in the home. One resident whose room had been recently decorated said that he was really pleased and he had just asked for a lock to be fitted to his door which was being actioned by the home’s handyman. All radiators are covered and bedroom doors have fire closures fitted. Several rooms and some of the communal areas have been re-decorated since the last visit and the home was clean and hygienic. The district nurse team provided the home with specialist equipment such as pressure relieving beds and moveable hoists and the nurses also provide training and support to the staff team. Both the residents and staff team at the home were exited about the changes to the environment and were looking forward to seeing the finished rooms. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 A caring staff team who are well trained and committed to providing a good level of care supports the residents of the home and there is a robust recruitment process in place EVIDENCE: There were five care staff, a cook, cleaner and handyman on duty during the visit. The day-care facility is separately staffed. During the night there are two waking staff with an on-call rota in case of emergencies. The staff team has worked at the home for a number of years and has built up good relationships with the people they support. Staff members were seen to be kind and caring and to treat residents in a respectful and patient manner. The home has robust recruitment and selection processes in place and records of staff recruited by the present manager were seen to contain all of the required documentation. Although all staff members have current Criminal Bureau Checks in place some of the older files do not contain two references or application forms. Mr. Manning-Smith is reviewing and updating these files as much as possible. A new induction programme is in place, which is in conjunction with the British Institute of Learning Disabilities and during the induction period new staff attend mandatory training. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 Page 18 Staff records show that there is a variety of training available including NVQ 2 and 3, challenging behaviour, diabetes, epilepsy awareness and protection from abuse. The deputy manager has also just completed NVQ 4 in Management. The residents in the home said that the staff team were very kind one person said, “It’s lovely here. Where I used to live before people moaned and groaned at me but people here are very patient”. Another person said, “ I am happy here, I like the food, the workshop and being helped to write”. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 35 36 37 38 The home is managed by a caring and competent manager who is working hard to improve the physical environment and improve the procedures and work practice in the home. EVIDENCE: Mr. Manning- Smith is to be commended on the changes he has already brought about within the home in the short time he has been the Registered Manager. As well as improvements in the physical environment the recording and work practices in the home have been improved and staff now receive an accredited induction. The staff on duty spoke very highly of Mr. Manning-Smith and said that he was approachable and supportive. Mr. Manning- Smith holds a management degree and is currently undertaking the NVQ4 and Registered Manager’s Award. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 Page 20 All residents have their own building society books and benefits are paid directly into their individual accounts. For monies kept in the home for residents all transactions are recorded and receipts kept for auditing purposes. The manager said that there was a financial plan in place in respect of the viability of the business and the home worked with an accountant to review and update the plan on a regular basis. There is evidence that staff receive supervision and appraisal with either the manager or deputy manager and a new communication book has been introduced to enable staff members to exchange current information. A quality assurance process is in place and questionnaires have been sent out to families and other professional people involved with the home. The comments received back have been very positive and Mr. Manning-Smith is now going to collate the information and publish it on the new information board in the hall of the home Records for the running of the home were seen including insurance and the policies and procedures manual, which has been completely updated in June 05. Staff are made aware of policies by a “policy of the month” initiative where staff read and familiarise themselves with key policies. Health and safety records were also seen including incident/accident forms and a new emergency fire pack for use during evacuation. Maintenance records were seen which included gas, electrical appliance testing, fire equipment, water temperature testing and hoist maintenance and all were current and in good order. One requirement has been made in respect mediation procedures. The Manor DS0000014783.V269374.R01.S.doc Version 5.0 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 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 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 3 3 3 3 3 3 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 3 3 3 3 3 3 3 The Manor DS0000014783.V269374.R01.S.doc Version 5.0 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. 1. Standard OP9 Regulation 13 Requirement Timescale for action Procedures for the administration and recording of medication 15/12/05 should be reviewed and updated 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 Refer to Standard OP1 OP7 Good Practice Recommendations The registered person should forward to the Commission the updated version of the Statement of Purpose and Service User Guide when building works are completed. Consideration should be given to further developing risk assessments to inform a plan of how the risk will be minimised. 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