Inspection on 10/12/06 for The Manor Cottage

This inspection was carried out on 10th December 2006.

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 Cottage 17/03/08

The Manor Cottage 15/01/06

The Manor Cottage 18/05/05

The Manor Cottage 20/02/05

The Manor Cottage 07/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Manor Cottage Beckspool Road Frenchay South Glos BS16 1NT Lead Inspector Melanie Edwards Key Unannounced Inspection 10th December 2006 09:30 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 Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor Cottage Address Beckspool Road Frenchay South Glos BS16 1NT 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) 0117 9560161 manorcottagecare@btconnect.com Manor Cottage Care Limited Mrs Marie Marcia Mowbray Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th January 2006 Brief Description of the Service: The Manor Cottage is a listed building, parts of which date back to the 15th Century. It has been carefully restored, with a large extension added to the rear. It is situated in the village of Frenchay within walking distance of Frenchay church and common. There are shops and other community amenities within one mile of the home and the centre of Bristol is four miles away. The Home is registered to provide personal care for up to twenty-six older persons. The property is built on three floors with lift access to each floor and a stair lift to two rooms. All bedrooms have en-suite facilities. Parking is available on the side and rear of the premises and there is a garden and patio areas that can be accessed by residents via french doors in the sitting room. The fees for staying at the Home range from between £380-£465 a week. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Twelve of the twenty-six residents currently living at the Home were consulted to find out their views. Two care staff and the cook were consulted about their roles and responsibilities, training needs, and how they assist and support residents. Staff were observed assisting residents with their needs. A portion of lunch was sampled in the company of a small group of residents at their invitation. A selection of records relating to the day-to-day running and management of the Home were inspected. A range of resident’s care records and care plans were also reviewed. The majority of the environment was seen with the only areas not viewed being a small number of bedrooms. There were a number of pre inspection feedback forms sent to the Commission for Social Care Inspection area office, from residents, and relatives. This information has been used to help form the judgments in the report. The Home was operating within the required conditions of registration set down by us. The conditions of registration detail the type of care and the needs of residents as well as the numbers of residents who may stay at the Home. What the service does well: What has improved since the last inspection? The lounge, the hallway and the dining room have been redecorated. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3. Quality in this outcome area is good. Residents are provided with the necessary information in the service users guide to make an informed choice about the Home. Residents’ needs are being assessed, and assessment records are reviewed to reflect changing needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the service users’ guide is kept in the entrance hall, and this is a well-frequented area of the Home. This helps residents and visitors to be able to find out the necessary information about the Home. There is also a copy of the last inspection report kept there .The guide was looked at to find out what information is available for residents and representatives. The service users’ guide is both detailed and informative. There were photographs of the Home included as well as the aims and objectives of the Home and the type of care to be provided. The name and contact details of the owners, along with experience of staff and the manager of the Home are also included. Three assessment records were read to find out how residents care needs are assessed. Assessment records were reasonably detailed and informative and The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 9 showed the Home had consulted with residents and their representatives to find out about the range of physical, mental and social needs the person had. There was also an assessment for each resident of his or her moving and handling needs. The assessment records had been reviewed and updated regularly which helps to demonstrate that residents assessed needs are being kept under review. The staff were seen to assist residents to meet their care needs in a friendly and kind manner. The care plans seen contained a range of information that showed how the Home meets residents’ needs. The residents consulted generally spoke positively about how their needs are met. Examples of comments made by residents included, `on the whole they do their best ’, and, `overall the service is good.’ These comments were reflective of the comments made by residents, and demonstrate they feel generally satisfied with how their needs are met. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8,9,10.Quality in this outcome area is adequate. Residents’ care plans demonstrate how needs are met. The practices and procedures for handling, storage and administration of medication are partly safe. Residents feel they are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were read to find out how residents are supported to meet their needs. The care plans seen were reasonably informative and explained how to meet the needs of residents. Care plans included guidance for staff to follow to support residents with physical, psychological, social and communication needs. To monitor residents physical health needs the Home keeps a record for each resident of when the person had seen the doctor, the optician, the dentist, and the reasons for the referral, and what treatment may be required. The records showed the GP sees residents on a regular basis to attend to their health care needs. The optician also comes to the Home for regular appointments to carry out eye tests on residents. This helps to demonstrate how the Home is ensuring that residents’ physical needs are met. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 11 Staff also keep day to day progress records for each resident to monitor their health and wellbeing. In discussion with care staff, they conveyed that they had an understanding of the residents they were caring for at the time. Care staff assisted residents in a polite and warm manner. Residents commented positively about the care they receive and how they feel their needs are met. Examples of comments made by residents included, ‘the staff are willing and helpful,’ `generally they are helpful’, and, `they are good I have no complaints.’ The practices and procedures in place for administration, storage and disposal of residents’ medication were checked to find out if the Home has safe systems for handling medication. A sample of ten residents’ medication administration charts were checked in detail. There was a photograph of each resident kept with his or her administration chart for ease of identification purposes. However, there was inconsistent information to assist staff when administering medication that was written as `give as required.’ Some residents’ medication charts had the necessary information written on them, and a number of the charts did not. There needs to be guidance in place to state when such Medication is to be given for the benefit of residents and to guide staff. Stock was generally satisfactorily organised and administration charts were being kept mostly up to date. There was a satisfactory system for ordering and receiving medication, and the records were up to date. Medication stock was stored in a movable metal drugs trolley, which is kept in a locked cupboard. There was some Temezepam medication kept, as required in the controlled drug cupboard. However one resident’s Temezepam medication was stored in the moveable drugs trolley. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15.Quality in this outcome area is good. Residents are provided with a range of social and therapeutic activities, and are supported to receive visits from family and friends, and to be a part of the local community if they so wish. Residents are also provided with a well cooked varied and nutritious diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the weekly timetable of social activities is on display in the entrance hall to ensure residents are aware of current and planned activities in and out of the Home. Residents take part in a range of low-key social activities, as well as regular trips out into the local community. There are regular outside entertainers who visit the Home, and several residents said that they were `good.’ There was also a range of information on display telling residents about forthcoming trips that are planned. Several residents said how much they were looking forward to a forthcoming trip to Cadbury Garden Centre, to see the Christmas lights, and to do some shopping. One resident went out for a walk to the local shops during the inspection. Also a small group of residents went to the local church for a morning service. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 13 The Home was also decorated in communal areas with Christmas trees and decorations; this enhanced the appearance of rooms for residents and made them look welcoming. Comments made by residents confirmed that they felt able to choose if they wished to what time that they get up, and go to bed. This was also observed during the inspection, with residents rising at differing times during the morning, and helps demonstrate residents can exercise choices in their daily lives. Residents were observed receiving visitors and the Home clearly operate a relaxed and flexible visiting policy. This should help to ensure residents keep in close contact with their families and friends. The Home operates a rotating menu, and menu choices were well balanced, and varied and special diets are also catered for. All of the residents who were consulted commented positively about the quality of meals provided. To check the quality of food provided a portion of a lunchtime meal was sampled in the company of a group of residents. This consisted of roast lamb roast potatoes, gravy, brussel sprouts, and parsnips. There was eves pudding for desert. The meal was tasty and well cooked. Catering staff were offering residents a choice of red or white wine, or fresh fruit juice with their meal. This is good practice and helps to enhance the overall service for residents. Care staff helped residents with their meals in the dining room, and were assisting them and talking with them in a friendly way. After residents had been served their meals and served tea or coffee, staff began washing up dishes, and tidying the kitchen. However residents started to become restless and were making comments asking for the staff. It would improve service at this time if staff assisted residents from the dining room after meals at the time that suits them. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16.Quality in this outcome area is good. Residents’ complaints about the service are listened to and acted upon wherever possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the complaints procedure is on display in the reception area, which includes the name of the Commission for Social Care Inspection, for anyone who wishes to contact us and make a complaint. The contact details of the owners are included in the service users guide and with residents’ contracts, if residents or representatives wish to contact the owners directly to make a complaint. Many residents also said that they felt able to speak to the manager, or the administration manager if they had any concerns and wished to complain. Staff were observed assisting residents and talking to them in a polite and respectful manner, which helps to demonstrate that staff are suitable to work with vulnerable residents in their care. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26.Quality in this outcome area is good. Residents live in an environment that is satisfactorily clean and well maintained. The Home is suitable for residents to live in and has the necessary adaptations and equipment in place to meet residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Manor Cottage Care Home is a large Victorian House built over three floors, which can be accessed by stairs or lift. The building is over two hundred years old is situated close to Frenchay village, and to the nearby local shops, a church and Frenchay Common. Specialist equipment and adaptations are in place throughout the Home, to assist residents and visitors who may have reduced mobility. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 16 The majority of bedrooms and all the communal areas were viewed. All bedrooms are for single occupancy. Rooms were satisfactorily decorated and maintained. The environment was clean and tidy throughout. Bedrooms have been personalised to reflect the tastes of residents with photographs, mementos and small items of furniture. The standard of furniture and fittings is satisfactory and residents asked said they liked the environment and setting of the Home. All rooms have en suite facilities, and there are bathrooms and toilets located within close proximity to rooms that do not have these facilities. There is also a washbasin in each bedroom. There is a dining room, a television lounge, and a small lounge located of the dining room. Residents were observed sitting in communal areas looking very relaxed and comfortable in the surroundings. Since the last inspection the lounge, the hallway and the dining room have been redecorated in light and cream colours. This further enhances the living environment for residents. Accessible toilets are located close to the dining rooms and lounges. Communal bathrooms were clean and well maintained and were free of any unpleasant odours. The home is well ventilated and warm with plenty of natural light. Radiators were fitted with guards throughout the Home, which helps maintain residents’ health and safety, so that they do not risk burning themselves. The environment was clean at the time of the inspection and residents confirmed that in general a high standard of cleanliness is maintained. There was soap and hand-towels available in the toilets and bathrooms this helps minimise the risks of cross infection in the Home. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,30.Quality in this outcome area is good. Residents are cared for by a sufficient number of trained competent staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff duty record for December 2006 was reviewed to find out how many staff are on duty to support residents with their needs. There had been a very small amount of sickness recorded and the Homes own staff had covered the shortfall in staff. There are at least four staff on duty during the early shift to provide residents with the support they need during the day. There are three staff on duty in the afternoon, and two members of staff work a night shift and are available for support if needed. The manager also works full time largely supernumerary hours during the week to support staff and residents. There are also full time catering staff, a cook, and part time cook as well as domestic staff working during the week. Based on the evidence seen during the inspection, the number of staff on duty is sufficient to meet residents’ needs. However, please see also comments made around staff actions at lunchtime, referred to earlier in the report. The training records of staff were not reviewed at the inspection. However there was information seen on display in the staff office that demonstrated staff attend training sessions, and updating in topics relevant to the needs of residents as well as in health and safety training. Two staff on duty explained what recent training they had attended. Both staff had completed an induction programme, as they are both relativity new The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 18 employees. This should help them learn to understand the needs of residents and the aims of the Home. To observe staff carrying out their duties, time was spent sitting in the communal areas while staff assisted residents. Staff were polite and courteous in manner when helping residents with their care needs. Staff were also asked about how they help residents with their needs. The staff consulted demonstrated an understanding of how they need to support residents with their needs. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,37,38.Quality in this outcome area is good. Residents’ benefit from the leadership and management in the Home. Also residents’ and staff health and safety is promoted and protected in the Home, and records are stored securely and residents’ rights are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mrs Mowbray has been the registered manager of the Home since 2004. She also has many years of experience working in senior positions in care home settings. This experience makes Mrs Mowbray suitable to fulfil the requirements of the role of registered manager. A full time administration manager supports Mrs Mowbray in her role. Several Residents commented that they thought the administration manager and Mrs Mowbray got on well together. Residents also said that Mrs Mowbray was friendly and kind and would `try to sort any problems out.’ The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 20 Residents individual records and the Home’s general records were kept secure in the Home.Care records were satisfactorily maintained, and in order. Records were kept in the office that could be locked when not in use. Generally the records seen were satisfactorily maintained and up to date, legible and in order and helped to demonstrate organised management and day-to-day running of the Home. Other records have been referenced elsewhere in the report. A number of residents said that Mrs Mowbray was approachable and listens to concerns and problems. This helps demonstrate resident’s views are listened to and acted on by the Home where possible. One of the owners carry’s out the required regulation 26 monthly monitoring visits of the Home to check on the overall quality of service provided. The reports of these visits demonstrate residents are being consulted on these visits. The environment looked to be safe and satisfactorily maintained throughout. There are regular health and safety checks of the Home carried out and a record of these checks as well as any action that is needed to ensure residents health and safety is maintained. A maintenance worker is employed to carry out routine repairs. This helps demonstrate the health and safety of residents, staff and visitors is being maintained. The fire safety risk assessment record was checked and showed an up to date risk assessment of the Home had been carried out, helping to maintain the safety of everyone inside the building. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 3 3 The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 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 OP9 Regulation 13.2 Requirement Where residents are prescribed medication `give as required’ guidance must be in place to state when such medication is to be given. All Temezepam medication must be stored in the controlled drugs cupboard. Timescale for action 17/12/06 2 OP9 13.2 17/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations Staff should ensure residents are assisted from the dining room after meals at the time that suits them. The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Manor Cottage DS0000051893.V316440.R02.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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