Inspection on 12/07/05 for The Manor House

This inspection was carried out on 12th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 House 15/05/08

The Manor House 16/05/07

The Manor House 18/05/06

The Manor House 07/02/06

The Manor House 13/01/05

The Manor House 18/05/04

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Snydale Care Home

Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Manor House Hall Lane Old Farnley Leeds LS12 5HA Lead Inspector Ann Stoner Announced 9.30am: 12th July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Manor House Address Hall Lane Old Farnley Leeds LS12 5HA 0113 2310216 0113 2310216 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Chamkaur Singh Dhaliwall Mrs Irene Foster Care home 30 Category(ies) of Old age (30) registration, with number of places The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 13th January 2005. Brief Description of the Service: The Manor House is a converted stone building that has been extended to provide residential care, without nursing, for older people. The home is located west of Leeds, adjacent to the local park, with a housing estate and bus routes nearby. There are 22 single and 4 shared rooms over two floors. A shaft lift gives access to the second floor. There are four communal lounges, separate dining space, three bathrooms and one shower room. Toilets are near to the lounge areas and bedrooms. The gardens are well maintained with outdoor seating areas. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 13th January 2005. There have been no further visits until this announced inspection. The people who live in the home prefer the term resident; therefore this will be the term used throughout this report. During the inspection, I looked at records and saw some areas of the home, such as bedrooms, lounges, dining rooms, toilets and bathrooms. I saw care staff carrying out their work and spoke with residents, visitors, staff, members of the management team and the owner (registered provider). Comment cards/questionnaires are left for residents, visitors and other professionals at each inspection, giving the opportunity for anonymous feedback. None have been returned since the last inspection. This inspection started at 9.30am and ended at 5.00pm, in addition to the time spent in the home, I spent time preparing for this inspection. What the service does well: What has improved since the last inspection? What they could do better: The home must improve its record keeping, particularly around assessments, care plans, medication records, complaints, and visits by the registered provider. Storage facilities for some types of medicines must be obtained, and some refurbishment, particularly in the laundry room must take place. The home should make sure that personal items of clothing, laundered in the home, are returned to their rightful owner. Staffing levels must be increased The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 6 and care staff should not carry out cooking and cleaning tasks. Staff training on adult abuse and a more thorough induction for new staff is needed. A number of requirements and recommendations have been made to address these issues. 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 House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 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 standard(s) 3 & 5. Standard 6 does not apply to this home. Residents are able to make an informed decision about the home, but information from the assessment is not enough to form the basis of the care plan. EVIDENCE: The home has a block contract arrangement with the Local Authority, but the manager said that she would not accept any referrals for admission until she has invited the prospective resident to visit the home and the home has completed its own assessment. The registered provider said that he did not put the manager under any pressure to fill empty beds; instead he placed emphasis on being able to meet the person’s needs. This is good practice. Residents said that they visited the home before admission. One person said that she visited several homes in the surrounding area before making her final choice. The home’s pre-admission assessment does not include information on dressing, personal hygiene, oral health, communication, continence, social The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 9 interests and family/carer involvement. Assessments are not always signed and dated by the person making the assessment, and there is no justification of how the home is able to meet assessed need. A recommendation has been made. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9. Care plans do not show how resident’s needs are met. The health care needs of residents are met, but some medication practices create the opportunity for error and there is a lack of proper storage for some medication. EVIDENCE: A good care plan is one that gives precise and detailed information on how and when care should be delivered, both during the day and at night, paying particular attention to the likes and dislikes of the resident in all aspects of care. The care plans at the home did not give this information, for example information such as ‘wears incontinent pads’ fails to give information on the type of pad and how often it should be changed. ‘Toilet regularly’ gives no information of when the person should go to the toilet, or of the level of assistance needed. Personal hygiene plans did not include information of when and how the person bathed, preferred toiletries, oral care, nail care, hair care etc. There were no night care plans or social and leisure care plans. There was no diabetic care plan for a person who has diabetes, and no plan for a person at risk of alcohol abuse. One resident has Parkinson’s disease, but there was nothing in his care plan to suggest that his ability to co-operate and self-care may change on a daily basis depending on his condition. Not all care plans were signed by the resident and/or his or her relative or representative, The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 11 and care plans are not reviewed at least once a month. The system of assessing risk does not show how the resident benefits from taking the risk, or the actions taken to reduce the risk. Risk assessments were not in place for all areas of risk. Records of visits by healthcare professionals are in care plans, and residents confirmed that their health care needs are met. One visitor said his friend’s health had improved 100 as a result of being in the home. The manager said that repeat prescriptions are ordered on behalf of the home by a local pharmacy, the medication supply is then delivered to the home. This system means that the home never sees the original prescription, which is contrary to guidelines issued by The Royal Pharmaceutical Society. There are no facilities for storing medicines that need cold storage or controlled medication. MAR (Medication Administration Records) are printed by the home’s supplying pharmacy, where amendments are required the home makes handwritten entries. These are not signed and dated by the person making the entry, the amount of medication received is not recorded, and the entry is not checked and countersigned by a second person. At times printed labels from the pharmacy are placed on the MAR. This is contrary to guidelines issued by The Royal Pharmaceutical Society. The home does not have a homely medication policy and senior staff were unsure on the use of homely remedies. One resident self-administered part of her medication, but this was not recorded on her MAR. A number of requirements have been made. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15. Residents are encouraged to make choices about their lifestyle. They are supported to keep contact with family and friends and visitors are made welcome. A good, varied and nutritious diet taking into account individual choices is provided. EVIDENCE: Residents and staff spoke of choices such as times for going to bed and getting up in the morning, and whether or not to join in activities. There is an extensive choice of menu, and residents spoke highly about the food, one person said, “The food is lovely and the choices are nice.” Another resident said that, by her own choice, she gets up at 5.45am and her breakfast is served as soon as she is ready. Care staff prepare breakfast for those residents awake before the cook starts work, they also prepare the teatime meal. Care staff do not wear any protective clothing when preparing, handling or serving food. A requirement has been made. Activities are provided but due to the lack of records the home cannot show if, and how, these are linked to past and present interests. Residents said that their visitors are always made to feel welcome. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 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 standard(s) 16, 18. Complaints are not always recorded therefore there is the opportunity that complaints will not be taken seriously or acted upon. The lack of staff training does not guarantee that proper procedures will be followed if abuse is suspected. EVIDENCE: Senior staff said that complaints are always taken seriously and acted upon, but they do not record, what they consider to be, minor complaints. A serious complaint made by a visitor was not recorded, although the manager said that this had been investigated. The home has a whistleblowing policy, but staff were unsure of what to do if they suspected the manager of abuse. Senior staff have had no training on the adult protection procedures. Requirements have been made. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 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 standard(s) 19, 25 & 26. Maintenance work is ongoing, but further refurbishment is required. The system of laundering soiled linen creates the opportunity for cross infection. EVIDENCE: There are well-maintained gardens, and throughout the day tree surgeons were working on cutting down some large trees that threatened the roof of the annexe building. The conservatory was hot, but the manager said that blinds are on order. A corridor carpet on the first floor has recently been replaced, but in places this is wrinkled, and could pose a trip hazard. The stair carpet is worn and needs replacing and some bedrooms need decorating. Some wedges were being used to hold open doors, but the manager said that this was with the approval of the fire officer. The water temperatures at several outlets were in excess of 50oc; the manager said that new valves are on order. There were many areas of risk of infection in the laundry room. The floor is not impermeable; there were large areas where floor tiles were missing. There were holes in the plaster on one wall, there was no liquid soap or paper towels, The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 15 there was soiled underwear soaking in the sink, there is no separation of clean and dirty linen, and clean linen is stored in this small area. Both visitors and residents said that items of personal clothing are not always returned after laundering. Liquid soap and paper towels are not provided in all areas where clinical waste is handled. Requirements and recommendations have been made. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30. Staffing levels are inappropriate for the needs of the residents, and induction for new staff does not meet the proper standards. EVIDENCE: Although there is a stable staff team, many staff work in excess of 48 hours a week, with nearly all working 12 hours shifts. There is only 1 part time cook and 1 cleaner, which means the manager and care staff have to undertake these duties. This takes them away from their caring responsibilities. There are 2 care staff on duty at night; given the layout of the building and the number of residents this is unacceptable. The home has an induction programme for new staff, but this does not meet the TOPSS (Training Organisation for Personal Social Services) standards. Requirements have been made. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 Personal information about residents is not secure and breaches confidentiality. Registered provider visits, required by regulation, are not carried out. EVIDENCE: A notice board in a corridor held information about residents’ names, dates of birth, GPs, appointment cards for out-patient clinics, and other personal information. This breaches both confidentiality and the Data Protection Act. The registered provider said that he visits the home twice a week, but does not keep a record of the visits. Requirements have been made. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 1 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x 2 x The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 19 N/A 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 7 Regulation 15 (1) Requirement Care plans must set out in detail the action that needs to be taken by staff to make sure that all aspects of health, personal and social care needs of the resident are met. Care plans, wherever possible, must be signed and agreed by the resident and/or their relative or representative. There must be a review of the care plan at least once a month. Risk assessments must be in place for all areas of resident risk. These must show the benefits to the person by taking the risk and the actions to be taken to reduce the risk. To make sure safe recording of medication, the home must order all repeat prescriptions, keep a record of the date and item ordered, then keep a record of the date and the amount of medication received. To make sure the storage of controlled medication in the home is safe, there must be proper storage and recording Timescale for action 31.10.05. 2. 7 13 (b) (c) 31.8.05. 3. 9 13 (2) 31.8.05. 4. 9 13 (2) 30.9.05. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 20 facilities. To make sure medicines are stored at the correct temperature a drug fridge must be obtained. To make sure the safe recording of medication all handwritten entries on MAR must be signed, dated, and show the amount of medication received. The entry must be checked and countersigned by a second person. Printed pharmacy labels must not be placed on the MAR. Where a resident self medicates or part self-medicates a record must be made on the MAR of when the medication was handed to the resident and the amount handed over. In order to make sure safe administration a homely remedy policy must be developed. To prevent the risk of infection, care staff must wear protective clothing when serving, preparing and handling food. The home must keep a record of all complaints, however small, with full details of the investigation and outcome. All senior staff, including the registered provider, must complete training on the use of the multi agency adult protection procedures. Care staff must complete training on adult abuse and they must be made aware of their right to contact the Adult Protection Unit, independent of the home. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 21 5. 9 13 (2) 31.8.05. 6. 7. 9 15 13 (2) 13 (3) 30.9.05. 31.8.05. 8. 16 22 Schedule 4. 18 13 (6) 31.8.05. 9. 31.10.05. 10. 19 23 The stair carpet must be replaced. The corridor carpet must be made safe. Door wedges must not be used to prop open doors. The registered manager must send evidence to the CSCI that this practice has the approval of the fire officer. Temperatures in the conservatory must be monitored and recorded with appropriate action taken to reduce the temperature if necessary. Pre-set valves of a type unaffected by changes in water pressure and which have fail safe devices must be fitted locally to provide water close to 43 degrees centigrade. The laundry floor must be made impermeable. Plaster must be replaced and the walls must be capable of being wiped clean. Liquid soap and paper towels must be provided in all areas where clinical waste is handled. This includes bedrooms, bathrooms, toilets and the laundry. There must be better seperation between clean and dirty linen in the laundry room. Clean linen must not be stored in this area. 31.10.05. 11. 19 23 (4) 15.08.05. 12. 25 23 (p) Immediate as advised. 13. 25 13 (4) (a) (c) 30.9.05. 14. 26 13 (3) 31.10.05. 15. 26 13 (3) 31.8.05. 16. 26 13 (3) 31.8.05. 17. 27 18 (1) (a) The staffing levels within the 31.10.05. home must be reviewed, with particular attention being paid to the staffing levels at night, the appointment of another cook and a cleaner. Version 1.40 Page 22 The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc 18. 30 18 19. 37 26 Schedule 4. All new staff must complete the TOPSS induction standards within the first 6 weeks of employment and the TOPSS foundation standards within the first 6 months of employment. The registered provider must complete visits in accordance with Regulation 26 of the Care Homes Regulations 2001. A record of the visit must be kept in the home and a copy must be sent to the CSCI. All information relating to residents must be kept secure. 31.10.05. 31.8.05. 20. 37 17 Immediate as advised. 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 3 Good Practice Recommendations The homes pre-admission assessment should include all the items listed in Standard 3.3 of the Care Homes for Older People - National Minimum Standards. The assessment form should be signed and dated by the person making the assessment. The assessment should include justification of how the home is able to meet assessed need. 2. 3. 4. 26 26 Water soluble bags should be used when laundering soiled linen. Measures should be taken to make sure items of personal clothing are returned to the right person after washing. The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Manor House J52 S1479 The Manor House V173951 120705 Stage 4.doc Version 1.40 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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