Inspection on 15/01/06 for The Manor Cottage

This inspection was carried out on 15th January 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 10/12/06

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 Unannounced Inspection 15 January 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.V272312.R02.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 Cottage DS0000051893.V272312.R02.S.doc Version 5.0 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.V272312.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2005 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 pleasant garden and patio area that can be accessed by service users via french doors in the sitting room. The Manor Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was planned and took place over one day. Sixteen residents and a number of relatives were consulted to find out their views. Mrs Mowbray, the administration manager, the cook, and one care assistant were also consulted about what their roles and responsibilities are, their training needs, and how they assist and support residents. The inspector ate lunch in the company of a group of residents at their invitation. A selection of records relating to the running and management of the Home were inspected. A range of residents’ records and care plans were also inspected, and staff were observed carrying out their duties. The majority of the environment was inspected with the only area not viewed being a small number of resident’s rooms. What the service does well: What has improved since the last inspection? 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 Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 6 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.V272312.R02.S.doc Version 5.0 Page 7 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): 3,4 Residents’ feel that their assessed needs are well met. EVIDENCE: Three assessment records were inspected to find out how residents needs are assessed. The records were informative, and showed a detailed assessment of the range of residents physical mental and social personal care needs had been carried out, and included information about how the Home intend to meet the needs. There was also a moving and handling assessment, which included an assessment of the risk to the person from falling. Residents changing care needs are regularly monitored due to the assessment being reviewed and updated on a monthly basis All the residents and relatives who were consulted expressed many comments of satisfaction about the care they receive. Examples of comments made included, ‘the service is very good no complaints whatsoever’, ‘the staff are very caring and helpful,’ ‘the staff are very nice and are really very kind.’ Several relatives also commented about the home, examples of comments made by relatives included, `all of the staff are lovely’ and, `it’s a very good home they are so considerate and kind’, and, `the staff are very very willing to do anything its very, very pleasant ’. The Manor Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 8 The Manor Cottage DS0000051893.V272312.R02.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 Care plans help to demonstrate residents’ needs are met monitored and reviewed, and residents feel their care needs are well met. EVIDENCE: Three resident’s plans of care were inspected to see how residents are supported to meet their personal care needs. The content of care plans included in detail how staff are to support residents with their physical and psychological personal care needs. Care plans were written in a simple and easy to follow style and stated clearly how to support residents to meet their needs. All of the care plans seen had been reviewed and updated on a regular basis, demonstrating care needs are being monitored and kept under review. Residents physical care needs are being addressed. There was a record kept for each resident of when the person had seen the GP, the chiropodist and other health care professionals. Staff were observed carrying out their duties and assisting residents through the morning, and during lunch. Staff were understanding and sensitive in manner when assisting residents with their needs. The Manor Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 10 The staff team were observed to be communicating well among each other and there was also a warm, respectful interaction between residents and staff. All of the residents the inspector met spoke positively about the very courteous and polite manner of all staff. The procedures for the administration storage and disposal of medication were inspected. The medication administration charts of three residents were inspected. There was a photograph of the resident kept with records to help to ensure medication is dispensed to the correct person as well as a medication administration profile, which details the preferred way that residents like to have their medication administered. The medication administration charts were legible, up to date, and contained the signature of the member of staff demonstrating resident’s medication is administered safely, the reasons for any omissions had also been written on the charts. Up to date records were also being kept of all medication being received into the Home, and medication being returned to the issuing pharmacy, showing there are safe systems in place to monitor how much medication is held in the Home. The Manor Cottage DS0000051893.V272312.R02.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): 12,13,15 Residents are supported to be a part of the local community, and to take part in a range of social and therapeutic activities, residents are offered a varied and well balanced diet. EVIDENCE: Three care assistants are allocated the additional responsibilities for providing social and therapeutic activities for residents. A number of resident’s spoke positively about the range of activities that are provided. Residents can take part in a range of social activities as well as gentle exercise classes. The Home also has access to a minibus, and there are regular trips to the community. There are notices on display for residents to be informed of the weekly planned social and therapeutic activities. There is also a regular newsletter that is published for residents to keep them up to date with in house events and news. Residents were observed leaving the Home to walk to local shops, and a number of residents said that there is a relaxed policy for receiving visitors who are always made welcome. The menu of meal choices that residents are offered was inspected to see what range of meals the Home offers. The menu was well balanced and varied. The The Manor Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 12 inspector sampled lunch in the company of a group of residents at their invitation. The meal consisted of roast pork, roast potatoes, mashed potatoes and fresh cooked vegetables; there was also a vegetarian alternative. Residents commented very positively about meals and said they thought the food they are offered was of a` very good’ and `satisfactory’ standard. Staff will ask residents on a daily basis what their preferred meal choices are for the following day. There are also alternative meal options available if residents do not like the two main meal options. The Manor Cottage DS0000051893.V272312.R02.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 There are procedures in place to help ensure that complaints about the service are responded to promptly, also there is staff training and a partly up to date procedure in place to help to protect residents from abuse. EVIDENCE: Residents and visitors should be able to know how to obtain the required information if they need to complain A copy of complaints procedure is on display in the Home .All of the residents who were asked said they would feel very able to speak to Mrs Mowbray, at any time if they had any concerns. Several residents said that Mrs Mowbray makes herself available each day to residents and walks around the Home to meet them. This helps residents know who the manager is and see that she is approachable. There is a policy and a range of supporting guidance information for staff to follow about the issue of the `protection of vulnerable adults from abuse’, However the policy needs to include up to date information about which organisations outside of the Home an allegation of abuse should be reported to This is to ensure all residents remain best protected. The inspector was also informed that all staff are provided with training to help them better understand the issues around the protection of vulnerable adults from abuse. The Manor Cottage DS0000051893.V272312.R02.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): 19-26 The environment is suitable to meet residents’ needs, and is clean and satisfactorily maintained. EVIDENCE: The Manor Cottage Care Home consists of a large property that is a listed building that overlooks Frenchay Common near Bristol. The Home is built over three floors, which can be accessed by stairs or lift. The building is over two hundred years old and is about a twenty-minute care ride away from Bristol City Centre. There are local shops a library, a church, pub and Frenchay Hospital is also nearby The environment was generally clean and tidy throughout. There are a range of specialist equipment and adaptations in place throughout the Home, to assist residents who may have reduced mobility. The Manor Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 15 The majority of bedrooms and all the communal areas were viewed. The majority of bedrooms are for single occupancy, however there are two double rooms. Rooms were generally satisfactorily decorated and maintained. All bedrooms have en suite facilities, and there are bathrooms and toilets located within close proximity to rooms . There are suitable adaptations in toilets and bathroom to assist residents with reduced mobility there is also star lift access to the second floor. There is a dining room, a television lounge, and a smaller television free lounge. Communal living areas were light, spacious and looked welcoming. Residents were observed sitting in communal areas looking very relaxed and comfortable in the environment. The Manor Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 The staff are competent to meet residents needs and recruitment procedures in place help to protect residents from harm. EVIDENCE: A selection of three staff recruitment records were inspected to find out if required ‘safety checks’ are being carried out when new employees are recruited. The required Criminal Records Bureau offences checks are being carried out for all new staff. These checks help ensure staff are suitable and `fit’ to work with vulnerable people, this helps protect vulnerable residents from potential risk of harm. There are also two professional references obtained for all newly recruited staff, also helping demonstrate the Home ensures the suitably of all new employees to work in the Home. The training records of three care assistants were reviewed to see if staff keep up to date with their knowledge and practice. There was evidence that demonstrated staff had attended training sessions, and updating over the last six months. To observe staff carrying out their duties, the inspector spent time sitting in the communal areas while staff assisted residents. Residents were being helped by staff who were good humoured and polite in manner. The Manor Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 17 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): 31,32,38 The Home is well run with staff who are supervised in their work, and there are systems in place that generally help protect the health and safety of residents, staff and visitors. EVIDENCE: The environment looked satisfactorily maintained throughout. There is a health and safety policy for staff to follow to try and help ensure the safety of residents is maintained. The fire logbook was checked and showed weekly tests of fire alarms being carried out. The fire fighting equipment was also being checked regularly, thereby helping to maintain the safety of those inside the building. There is a record to show staff attended fire safety update training in the last twelve months. This should help ensure they are aware of fire safety procedures in the Home. To help ensure the environment is safe for residents Mrs Mowbray and the The Manor Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 18 maintenance worker take responsibility for health and safety matters and carry out regular health and safety checks of the environment. A number of residents were asked if they knew Mrs Mowbray, and did they see her regularly. While many residents said Mrs Mowbray was often very busy they also said she was very kind, and she would gladly make time to see them if they needed to speak to her. A full time administration manager is also employed to oversee the running of non-clinical management areas of the Home. Mrs Mowbray and the administration manager evidently work well together and liaise on a day-to-day basis about matters relating to the running of the Home. The Manor Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 19 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 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 X 3 The Manor Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 20 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. 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. 1 Refer to Standard OP38 Good Practice Recommendations The `Protection of vulnerable adults from abuse’ policy should be updated and reflect current guidance. The Manor Cottage DS0000051893.V272312.R02.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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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