Inspection on 12/10/05 for The Manor House

This inspection was carried out on 12th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Manor House 01/11/06

The Manor House 25/02/06

The Manor House 22/03/05

The Manor House 09/12/04

The Manor House 24/03/04

The Manor House 18/11/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 The Manor House 72 Church Street Market Deeping Lincs PE6 8AL Lead Inspector Alison Marshall Unannounced 12 October 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Manor House Address 72 Cburch Street Market Deeping Lincs PE6 8AL 01778 344921 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) Sense East Mrs Sylvia Welford Care Home Only 7 Category(ies) of SI - Sensory Impairment - 7 registration, with number LD - Learning Disability - 0 of places The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 22 March 2005 Brief Description of the Service: Manor House is part of the SENSE organisation and is registered to provide care and accommodation for up to six service users over the age of eighteen years affected by deaf/blindness caused by rubella. This home shares a site with Manor Court, another care home and within the grounds are a patio, garden, hydrotherapy swimming pool, interactive multi-sensory room and administrative offices. Service users attend a day care facility in Peterborough also managed by SENSE. Transport is provided through the use of a minibus or via a regular bus service. The home is located in the town of Market Deeping, which has a variety of facilities and services. The stated aim of the home is “to provide a safe and supportive environment based on best care values for people who are deaf/blind. To promote a presence in the community by the use of local amenities and services, maintaining good relationships and promoting a positive image of residents of Manor House ”. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out between 10:00 am and 4.00 pm. Time was spent talking with the manager, the staff on duty and looking at records. One service user was on a home day and spent most of the day out with staff support in the community. The other service users were attending the Sense workshop in Peterborough. The inspection focused on records and discussion with staff. The next inspection will be made at a time when service users will be present. This was a positive inspection with no requirements or recommendations being made. What the service does well: What has improved since the last inspection? What they could do better: There were no requirements or recommendations made. The home is well managed and receives good support from within the organisation. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 6 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 C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 4 Admissions were well planned and ensured a smooth transition for new service users. EVIDENCE: One service user had moved into the home in March 2005. A full assessment had been carried out and staff had visited his previous placement and talked with family and other professionals. Following this a there was a planned transition allowing the service user to spend short periods of time at Manor House before moving in. Parents of the service user described the move as ‘well organised’ and felt that as a result the move had been made very easy. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Service user individual needs were promoted and documented appropriately. EVIDENCE: All service users had individual files and plans that were stored in the office. The files and plans were clear and well organised. The care plan file contained all of the working documents: the care plan itself with targets set in areas such as self help, making choices, leisure activities and communication; the pen picture was an assessment of the individual’s level of functioning in all areas of life; functional assessments of hearing and vision and behaviour management guidelines were clear and detailed as was the communication profile. All individual documents were updated following the annual review. Other files contained records relating to health and finance and general correspondence. A communication log for each individual contained daily written logs. The folder in which these were contained went back and forth between Manor House and the Sense workshop in Peterborough and so provided a 24 hour record of the individual service user. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 10 From the records and discussion with staff it was apparent that service users were encouraged to make as many decisions for themselves as possible. Staff supported service users to take as much responsibility as possible for daily domestic chores. Risk assessments for individuals were in place. The Sense Health and Safety Officer carried out the annual Health and Safety audit on the same day. He said he was planning on providing risk assessment training for Sense staff as he felt written risk assessments could be improved upon. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 and 17 Service users had busy and varied lifestyles with opportunities to engage in a range of educational, vocational and leisure activities. EVIDENCE: Records and discussion with staff showed that service users participated in a range of individual and group activities within the local community. These included yoga, swimming, bicycle rides, shopping for food and clothes and visiting the local pub. All service users went on an annual holiday. Two service users had been away the week before in Derbyshire. Service users attended the Sense workshop or had dedicated home days. On home days staff would support service users on a 1:1 basis. These days could be used for a number of different activities decided upon the individual. Within in the house service users undertook most of the domestic chores, individually and for the group, with staff support. Staff encouraged healthy eating through assisting with menu planning and food shopping. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 12 Family members were encouraged to visit at any reasonable time. Service users were supported to maintain contact through visits, telephone calls and letters. Staff provided appropriate guidance and support to service users with regards to personal relationships to ensure they had sufficient information on which to make safe choices. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Service users received personal and health care in line with their needs and independence in all areas was encouraged. EVIDENCE: Each service user had an individual health file. These were clear and well organised and showed that service users had appropriate input from a number of health agencies. Records showed regular visits to the GP, dentist and optician and other health professionals. Care plans detailed the support required by individuals in terms of their personal care. Medication records and storage were satisfactory ensuring that all medication was administered safely and correctly. The deputy manager oversaw medication and carried out a monthly audit of stocks and records. In addition the pharmacist visited every three months. Only staff that had received training administered medication. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 There were good systems in place to ensure the safety of service users. EVIDENCE: There had been no complaints made since the last inspection. Adult protection was covered within staff induction training and staff spoken with were aware of the policy and procedure although the procedure had never had to be initiated. The management were aware that this was an area that needed to be readdressed to keep it in the forefront of staffs’ minds. As a result, the manager said that adult protection was going to be included as a discussion point in forthcoming staff appraisals. All staff would have to complete a written questionnaire which included examples of adult protection scenarios. Sense had a dedicated behaviour advisor to support staff and service users in managing behaviour. Each service user had an individual behaviour management plan that detailed the behaviours, gave possible reasons behind the behaviours, precursors, triggers and de-escalation strategies. The guidelines were reviewed regularly. All incidents of behaviour and the use of physical intervention were recorded. The records were signed by the manager and sent to the behaviour advisor who monitored them. Copies of the records were also kept on individual files. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30 Manor House was generally well decorated and maintained and suitable for the needs of the service users. EVIDENCE: A tour of the premises showed that the Manor House was generally well maintained and decorated. The home looked clean and tidy and no unpleasant smells were noticed. Rooms were very individual in terms of decoration and belongings. Individual room entry systems were provided for each service user. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 Service users were well supported by a small competent dedicated staff team ensuring consistency in practice and support. EVIDENCE: The manager said that the home was fully staffed and that agency staff were not used. Rotas showed that there were four staff on for six service users. There was a shift leader on each shift. Staff underwent the Sense Induction programme and also followed an in house induction. Staff recruitment files were well organised and showed that all of the checks required by law were carried out. Files also showed that regular staff training too k place. Staff confirmed that they received regular supervision and annual appraisals and that these were recorded in writing. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 There were good systems in place to monitor the performance of the service. EVIDENCE: Sense employed a Health and Safety Officer who undertook comprehensive yearly health and safety audits. One was completed on the day of the inspection. The Health and Safety Officer produced a report with actions to be taken. He also provided regular health and safety bulletins and gave advice to staff when necessary. All accident reports were copied into him. From these he was able to identify further action that needed to be taken as well as training opportunities. There were a number of systems in place to review the service provided. The area manager carried out monthly visits as required by regulation 26 of the Care Home Regulations 2001. The regional behavioural advisor monitored all incidents of challenging behaviour. As mentioned above the Health and Safety Officer monitored all accidents. Each service user had a review every six months at which to discus their needs. The Policy and Quality Control The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 18 Department carried out an annual audit in which the views of parents and staff were sought. The review was written up and an action plan developed from this. The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Manor House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 20 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 Regulation Requirement None made 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 None made Good Practice Recommendations The Manor House C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 C53 C04 S2454 Manor House V247193 12-10-05 Stage 4.doc Version 1.40 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!