Inspection on 17/03/08 for The Manor Cottage

This inspection was carried out on 17th March 2008.

CSCI found this care home to be providing an Good service.

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 10/12/06

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 Bristol S. Gloucestershire BS16 1NT Lead Inspector Melanie Edwards Unannounced Inspection 17 March 2008 09:45 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.V359674.R01.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.V359674.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor Cottage Address Beckspool Road Frenchay Bristol S. Gloucestershire BS16 1NT 0117 956 0161 0117 956 5336 manorcottagecare@btconnect.com 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) Manor Cottage Care Ltd To be appointed. Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th December 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 £470-£525 a week. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. We (the Commission) met fifteen of the twenty-three residents at the Home. We also met a number of visitors. We met the acting manager, the administration manager, three care assistants, and the chef. We spoke to them about their roles and responsibilities, their training needs, and how they assist and support residents. We had lunch with a group of residents. Residents were observed being helped with their needs by staff. A sample of records relating to the day-to-day running and management of the Home were read. These included staff training files, staff recruitment files, staff duty rotas, the fire logbook record, maintenance records, menus, and medication records. Three residents care records and care plans were read. Most of the environment was seen. The only areas not seen were a small number of bedrooms. What the service does well: Residents are treated in a very kind and polite way by the staff, and their needs are well met. Residents made a range of comments including, ‘ the staff are wonderful if I need anything I just ring the bell ’, and, ` the staff are 100 percent helpful ’. Residents can do a variety of low-key social and therapeutic activities. Residents’ are provided with meals of a good quality, that are nutritionally well balanced, and varied. The environment is suitable for residents and is decorated to a good standard that enhances the Home. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 6 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 summary of this inspection report can be made available in other formats on request. The Manor Cottage DS0000051893.V359674.R01.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.V359674.R01.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): 1,3,6.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information they need to make an informed choice about the Home. Residents’ assessed needs are met. However more regular review of assessment records could be an extra safeguard to protect residents skin integrity. Residents are not provided with intermediate care at the Home. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 9 EVIDENCE: To check what sort of information is available for prospective residents and their representatives a copy of the service users guide and statement of purpose were read. Each resident is given their own copy of the guide so they have access to helpful information about life in the Home. There are colour photographs of the Home, and of staff and residents together, to show what daily life is like at Manor Cottage. The service users guide and statement of purpose include information about the service, the qualifications of the staff employed, and the accommodation. The philosophy of the Home and how the service aim to meet residents needs is included. The complaints procedure is in the service users guide so residents know how to complain if they need to. The assessment records of three recently admitted residents were read to find out how well residents’ needs are assessed. The assessment records contain information about each resident and how they are helped to meet their needs The records include information about each person’s mobility needs, risk of falling, and their skin integrity. The majority of the assessment records had been reviewed regularly. However the assessments of two peoples skin integrity had not been reviewed since November 2007,the third resident had only just been admitted. It is beneficial that assessment records are reviewed each month. This is to demonstrate action is taken, if needed so that resident’s skin stays in good condition and does not ‘ break down ’. There is no provision for residents to be provided with intermediate care at the Home. The Manor Cottage DS0000051893.V359674.R01.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 good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met and care plans help to demonstrate this. Residents are treated with respect and their privacy is upheld. Residents medication is handled administered and disposed of safely. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three care plans were read to see how residents care needs are met. The care plans include information to show how to meet each person’s physical, social, and communication needs. The care plans show how to meet the care needs of each person. The care plans set out what actions staff should follow to assist the resident to meet their needs. The care plans are reviewed and updated regularly to show residents care needs are monitored and kept under review. There was up to date information in care plans to show residents are supported with their physical health care needs by the GP, the dentist, and the chiropodist. The acting manager contacted a GP during the inspection to ask them to come and visit and attend to one resident’s health needs. A district nurse also visited the home to attend to the nursing needs of one of the residents. We saw staff help residents in a polite and friendly way. Staff were also observed knocking on bedroom doors before entering them. All of the residents who were consulted spoke positively about the attitude of staff (as has already been referred to). The residents we met said staff are polite to them. The procedures for the administration, storage and disposal of medication were inspected to find out if the systems are safe. All staff that give out medication do training to make sure they give out medication safely. Residents’ medication is stored in a locked cupboard. Eight residents medication administration were checked. There was a photograph of the resident kept with each chart. The medication charts were satisfactorily maintained, legible and contained the signature of the person dispensing medication. The reason for any medication omissions had been recorded on the administration charts. The controlled drug record was in order, and the supply of controlled drugs was randomly checked .The records were correct, this shows medication stock is well organised. The Manor Cottage DS0000051893.V359674.R01.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. This judgement has been made using available evidence including a visit to this service. Residents receive a well-cooked, and nutritious diet. Residents are able to take part in a variety of low-key social and therapeutic activities. Residents are supported to receive visits from family and friends. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 13 EVIDENCE: There is a copy of the monthly timetable of social activities planned to take place put on display in the Home for residents to read. This helps to ensure residents are aware of activities that will take place. Activities that are planned for the near further include, arts and crafts sessions, games and musical afternoons. We saw staff engaging residents in a musical afternoon with a Karaoke machine. Residents looked relaxed and were enjoying this activity. A number of residents had visits from family and friends. Visitors said that the staff are welcoming and friendly to them. The Home has a relaxed and flexible visiting policy. This benefits residents as this means they can keep in contact with family and friends. We checked the residents’ menu, and it demonstrated residents are provided with a well balanced diet. The daily menu choices are put out on display in the dining room hall for residents to read. The meal options seen were nutritionally well balanced and varied. There are alternatives available each day. The staff ask residents what they wish to eat each day. Special diets can be catered for and there are a variety of special meals provided for residents who need them. A portion of the lunchtime meal was sampled in the company of residents. This was a homemade Irish stew (to recognise that it was St Patrick’s Day) with mashed potato and vegetables followed by apple crumble for desert .The meal was tasty and nourishing. Residents we met commented positively about the food served at the Home. The Manor Cottage DS0000051893.V359674.R01.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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ complaints are taken seriously and are well responded to in the Home. Residents are protected from abuse. However a more robust training programme for staff on the topic of abuse would further benefit residents. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 15 EVIDENCE: The residents we met told us they see the acting manager and she walks around the Home to meet them. Residents said they speak to any of the staff about any concerns they may have. Residents are given their own copy of the Homes complaints procedure. This helps to make sure residents have the information they need to make a complaint. The complaints procedure includes the contact information for the Commission if a person wants to contact us directly. There is an up to date policy in place about the issue of protection of vulnerable adults from abuse. The policy is to help to guide staff to take the correct course of action if they ever have to respond to an allegation of abuse. We looked at staff training records to check if the staff team have done recent training on the principle of the protection of vulnerable adults from abuse. The records we saw demonstrated that a significant number of the staff have not done recent training, although some of the team have. It would be beneficial for residents and staff if all staff do training on the subject of `protection of vulnerable adults ’. This is to keep staff up to date on what they must do to protect residents from the risk of harm or abuse. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 16 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): 19,22,23,25,26.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a Home that is safe well maintained, and suitable for meeting their needs. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 17 EVIDENCE: Manor Cottage Care Home is a large House built over three floors, which can be accessed by stairs or lift. Parts of the original building date back over five hundred years. It is situated close to Frenchay village, to local shops, a church and Frenchay Common. The environment was clean and satisfactorily maintained. There was soap and paper hand-towels available in the toilets and bathrooms to minimise the risk of cross infection in the Home. Residents’ bedrooms are for single use. Rooms are satisfactorily decorated and maintained. The environment was clean and tidy throughout. Residents have personalised their bedrooms with photographs, mementos and small items of furniture. The standard of furniture and fittings is satisfactory. The residents we asked said they liked the environment and setting of the Home. All of the bedrooms have en suite facilities and a washbasin in each bedroom. There is a dining room, a television lounge, and a small lounge located of the dining room. The communal areas are decorated in light, cream colours. We saw residents sitting in communal areas looking relaxed and comfortable in the surroundings. There are toilets situated near to the dining room and lounges. The bathrooms were clean and satisfactorily maintained and were free of any unpleasant odours. The environment is well ventilated and warm and there is plenty of natural light. Radiators are fitted with guards throughout the Home, which helps maintain residents’ health and safety, so that they do not risk burning themselves. We saw specialist equipment and adaptations throughout the Home to assist residents and visitors who may have reduced mobility. The environment was clean and satisfactorily maintained. There was soap and hand-towels available in the toilets and bathrooms to minimise the risk of cross infection in the Home. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 18 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): 27,28,30.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a sufficient number of competent, qualified staff. Residents’ benefit from being cared for by staff who do some training and have a good understanding of their needs. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 19 EVIDENCE: We looked at the staff duty record for March 2008 to check on how many staff are on duty to support residents. There was a small amount of sickness recorded on the rota for March. The Home covers shifts with staff that the residents know to ensure they are given continuity of care. There are four carers on duty during the morning shift, and three carers in the afternoon. There are two members of staff on duty at night. Based on the evidence seen the number of staff on duty is sufficient to meet residents’ needs. Catering, domestic and ancillary staff also support residents although the numbers of the staff were not checked. The training records of the staff team were looked at to see if staff are keeping up to date in their knowledge of the needs of residents. There was evidence that staff had attended training sessions, and updating over the last twelve months. There was information on display in the office that demonstrated staff are booked to attend forthcoming training in food hygiene, first aid and fire safety. The staff communicated and supported residents in a polite and friendly manner Residents spoke positively about how the staff help them, one resident said,‘ the staff are very helpful ’, another resident commented, ‘ they do their very best ’. The staff meetings minutes record showed that staff meetings take place on a regular basis and staff are consulted about a range of relevant matters related to the day-to-day running of the Home. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 20 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): 31,33,35,36,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ live in a Home run by a person who should be suitable to fulfil the requirements of the role, and able to run the Home in their best interests. Residents are cared for by staff who are appropriately supervised. The health and safety of residents and staff is protected. Residents’ finances are well protected in the Home. EVIDENCE: Ms Attewell is the acting manager. She has been working at the Home since December 2007. She has many years of experience caring for people with a range of needs, and in running Care Homes. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 21 Before she worked at Manor Cottage she was registered with us as the manager of other Care Homes in Avon that provide Nursing Care. This helps to demonstrate she is fit and competent to be a manager. We met some residents who said they see the acting manager reasonably regularly when she walks round the Home. The acting manager has been carrying out a quality audit to check on the quality of the care and the service residents receive. We looked at a copy of the audit tool that is used. The acting manager has recently reviewed and audited the care and the service in different areas of the Home. The acting manager has undertaken the annual service questionnaires with residents and relatives .We were told that the information will be used to improve standards even more in the Home. The administration manager takes responsibility for looking after residents finances if needed .Residents we met talked fondly of the administration manager who they said was very helpful . Finance records were avaliable for inspection but they were not looked at on this occasion.There is a secure safe to keep residents money and valuables in . The staff told us that the acting manager supports the staff with regular one to one supervision sessions. The supervision records that we looked at demonstrated staff are being well supervised and supported. Residents’ records were satisfactorily maintained, up to date, legible and in order. The records relating to the management of the Home were also satisfactorily maintained and in order. Individual records and the Home’s records are kept secure, and are available to staff when needed. Other records are referenced elsewhere in the report. The environment looked satisfactorily maintained throughout. The acting manager has started doing regular health and safety audits of the whole environment, to make sure it is safe. All staff do health and safety training in range of areas including food hygiene, fire safety, and infection control. This helps ensure staff have a good understanding of health and safety principals and practises. The fire logbook record showed fire alarm tests and drills are being done regularly. The kitchen was clean and tidy and in good order. All kitchen staff do regular food hygiene training to ensure they have a good understanding of safe practises for preparing and cooking food. The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 X X 3 3 X 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 3 3 X 3 The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 23 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. 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 OP3 Good Practice Recommendations The assessment records used to monitor residents skin should be reviewed each month This is to demonstrate action is taken if needed, so that residents skin stays in good condition. All staff should do regular training on the subject of `protection of vulnerable adults ’. This is to make sure staff are clear on what they must do to protect residents from the risk of harm or abuse. 2 OP18 The Manor Cottage DS0000051893.V359674.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South West Regional Office 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA 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.V359674.R01.S.doc Version 5.2 Page 25 - 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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