Inspection on 16/06/05 for The Manor House

This inspection was carried out on 16th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 09/12/09

The Manor House 14/03/07

The Manor House 23/02/06

The Manor House 10/02/05

The Manor House 24/06/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

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 House 135 Looseleigh Lane Derriford Plymouth PL6 5JE Lead Inspector Sheila Giblin Announced 16 June 2005 th 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 D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Manor House Address 135 Looseleigh Lane, Derriford, Devon, PL6 5JE 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) 01752 778280 01752 778280 Welling Ltd Mrs Kathryn Margaret Daw Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2005 Brief Description of the Service: The Manor House is registered to provide residential accommodation and care for a maximum of thirty older people. The home is situated in the Derriford area of Plymouth, and is a detached older property that is set in its own grounds. The home is owned by Welling Ltd, who own a number of care homes in the South West of England. The Registered Manager is Mrs Kathy Daw. Care is provided on two floors, and to assist service users who have mobility difficulties a passenger lift has been installed. The living rooms are on the ground floor and consist of a large spacious lounge and a smaller lounge with one dining table. The main dining room is also located on the ground floor. The home has twenty eight single bedrooms. of which seventeen bedrooms have en suite facilities, and one double room if partners wish to share. The home has appropriate disability aids and adaptations to assist and encourage residents to be independent and mobile. The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A pre -inspection questionnaire had been completed prior to the inspection and gave information as required. Questionnaires sent out by the Commission had been completed and returned. The inspection was announced and took place over nine hours. It included the inspection of records and documents, a tour of the building, discussions with the owner Mr Alan Beale, the registered Manager, Mrs Daw, the administrator and other staff on duty. All the residents were introduced to the inspector and twelve gave accounts of their lifestyle in the home. A visitor to the home described their relative’s experiences as very beneficial. What the service does well: The atmosphere in the home is lively, positive and welcoming. The Manor House provides spacious well-furnished accommodation in a large detached house which has been extended to provide 28 single bedrooms, 17 with ensuites, plus one double room for a couple. The home is very clean and tidy and well maintained by the regular maintenance person. The grounds provide accessible landscaped gardens with patios, pathways and lawns where residents and visitors can take advantage of this attractive outdoor space for exercise or relaxation. Recording systems and record keeping are very well managed. Care services are well organised by the Registered Manager, Mrs Daw, and the key worker system ensures individual attention is provided for personal requirements and errands. Every resident who spoke to the inspector described their admission to the home and their daily experiences as being most satisfactory. Mrs Daw, the manager, was described as an excellent manager and a very kind and caring person. The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 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 Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 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 D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 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) 1, 2, 3, 4, 5, 6 Prospective residents and their representatives can be confident of a warm welcome when visiting the home and are assured of a professional assessment of care needs. EVIDENCE: Residents’ records and contracts showed clear information regarding the terms and conditions of occupancy at The Manor House including fees to be paid and the number of the room to be occupied. The Statement of Purpose and Service User Guide described everything about the home and were available for prospective residents and their representatives to be able to make a choice about whether they wished to live there. Preadmission assessments are carried out when prospective residents visit the home if possible. Mr Beale, the owner, writes to all prospective residents stating that the home can or cannot meet the assessed needs and sets out some information regarding the terms and conditions of admission to the home. The letter was clearly written. Residents and relatives seen during the inspection said they had visited the home prior to admission and had enjoyed the welcome they received. Some residents had chosen the home following recommendations from other residents past and present. Intermediate care is not provided at The Manor House. The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 10, 11 Residents can be confident that their health and care needs will be met. EVIDENCE: Residents’ records showed evidence of GP and Community Nurse input. The visiting Nurse commended the staff and manager in the home for the high standards of professional care she had seen them providing when she visited. Residents said they had been well looked after when not feeling very well. They said staff were attentive and always answered the call bell promptly. A visitor said that the health of their relative had improved significantly since living in the home. Everyone who spoke to the inspector said that they were treated with the utmost respect and dignity. Some described the procedure followed when they were assisted to have a bath. They said their privacy was respected and they were given enough time to enjoy the bath and never rushed. They had their own toiletries to use in the bathroom. The Manor House has clear policies and procedures to follow when someone dies in the home. Mrs Daw, the manager, said that residents could remain at the home if they became frail as long as their needs could be met by the staff and district nurses when necessary. Visitors could stay with residents if they wished during their final hours. The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 10 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, 14, 15 Residents at The Manor House are assured of a relaxed and stimulating lifestyle that respects their wishes and abilities. EVIDENCE: The routines in the home were said to be flexible and organised to suit the residents’ preferences. A resident who needs help with getting dressed each morning said that staff always answered her call bell with a cup of tea, then provided the attention she needed. She had never had to ring the bell twice in the seven years she had lived in the home. Another resident said staff offered to help every day and sometimes she needed it and other times she could manage herself. She appreciated and valued staff’s consideration in respect of her independence and privacy. Visitors spoken to said they were free to visit when they wished and were always welcomed by friendly staff and offered a cup of tea. Residents described the leisure activities. They include a variety of entertainments, physical exercise and games provided weekly and fortnightly. Residents are encouraged to go out on trips in a sixteen seater bus at least 3 or 4 times a year. Quizzes and reminiscence, karaoke and music provide stimulation and enjoyment. Students from the local College put on a play for the residents recently. Lunch was served during the inspection. The inspector sat with residents and noted their satisfaction with the meal. Those residents who commented on the food they were served said that it was much improved since the new cook had The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 11 taken over. The meal was well received and residents said it was hot and tasty. The dining tables were attractively laid up with fresh table linen, silverware and crockery in the recently refurbished dining room. The meal-time was leisurely and residents were served by attentive staff. Residents who may require some help to eat are served in the small lounge/dining room where their dignity and privacy can be preserved. The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 12 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 Residents and their relatives can be confident that any complaints they make will be taken seriously and acted upon promptly. EVIDENCE: The complaints procedure and appropriate information is posted on the notice board, contained in the Statement of Purpose, Service User Guide and in the Terms and Conditions. The Registered Manager records all comments and complaints no matter how small and uses the information to constantly review services and make improvements if necessary. The Commission has received no complaints in respect of the Manor House. The manager has attended POVA training and she cascades the information to staff to ensure they are aware of the issues about abuse and protection. The newly published Alerter’s Guide was on display in the office. All residents are on the Electoral Register. The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 13 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, 20, 21, 22, 23, 24, 25, 26 Residents live in a very well maintained home that is comfortable and safe. EVIDENCE: The Manor House is located in a level position in a residential area on the outskirts of Plymouth near Derriford Hospital and the airport. Accommodation is provided on two floors with some steps between. The passenger lift has access to all levels. The lounges and dining rooms have been very tastefully decorated and were awaiting new curtains at the time of the inspection. New dining room furniture was on order. Residents were very pleased with the work that had been carried out. The gardens are easily accessible from the house. They have been laid out to offer walkways and seating areas for residents and their visitors. During the summer months residents said they spent a lot of time in the gardens enjoying the trees and flowers and wild life to be seen there. The Manor House has been assessed by an Occupational Therapist and some recommendations made and carried out. There are five bathrooms located around the home and a shower room on the ground floor. All bathrooms must The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 14 have an appropriate lock that can be overridden by staff in the event of an emergency. The small bolt on the door of the middle bathroom with the hoist must be removed. All residents’ bedrooms were pleasantly decorated, comfortably furnished and were personalised with their own pictures and ornaments. Rooms were clean and tidy and reflected the personality of the resident living there. Residents said that staff always knocked on the door before entering. One resident with sensory impairment has a flashing light which is activated to alert her when someone knocks on the door. Residents said they liked their rooms and there are no restrictions as to when they can use them. Some residents spent most of their time in their rooms and took meals there if they wished. Radiators have been covered to ensure residents are safeguarded from burns from hot surfaces. Water temperatures are regulated by temperature regulation valves. These measures have been designed to protect residents from the risk of scalding. The new washing machine has a sluicing/ pre-wash programme to deal with any soiled linen. A sterilising facility is incorporated in the washing programme to reduce the risk of cross infection. The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 15 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, 28, 29, 30 Residents can be confident that there will be enough experienced and knowledgeable staff on duty who are committed to meeting their needs. EVIDENCE: The staff team is led by the Registered Manager and is made up of a deputy manger, senior carers, care assistants, domestic assistants, cooks and handyman. The office administrator oversees the clerical and accounting systems. Staff turnover in the home is low with just one change in the previous year. All the residents said they liked the staff and had confidence in them to look after them properly. Over 60 of staff hold the NVQ2 Certificate. The home’s recruitment policy and procedure were clear and robust. Staff files included application forms, references, CRB check numbers, photographs of staff employed and an employment contract/ terms and conditions. Staff training has been recorded on the training and development programme that carries its own budget. The manager has identified POVA and Diabetes as training needs. The manager uses Video training for dementia awareness plus a course. Medication training has commenced by means of a 12 week correspondence course followed by a practical assessment. Fifteen staff have a first aid certificate. One staff member employed as care support, is under eighteen years of age. She will become a trainee in October 2005 and will begin NVQ2. The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 16 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) 31, 32, 34, 35, 36, 37, 38 Residents can be confident that the home is well managed by an experienced and able manager. EVIDENCE: The Registered Manager, Mrs Kathy Daw, is a first level Nurse who holds the Assessors Certificate. She is in the process of the Registered Manager’s Award and is due to complete it in 2005. Mrs Daw has managed The Manor House for 6years. She is supported by a deputy manager. The atmosphere in the home was lively and positive. Staff and residents commended the manager for her professional approach and kindness. Mrs Daw was said to have an open and transparent management approach that recognised the need to maintain confidentiality and respect privacy as needed. Staff and residents’ meetings are held and minutes taken. Staff supervision is carried out at least six times a year. Suggestions and comments are followed up for example changes to the menu and activities have been taken on board. The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 17 The accounting and financial procedures in the home are managed by the administrator and closely audited by the owners monthly. Plans for redecoration and refurbishment were seen. Accounts showing the balance of income and outgoings were provided. Residents financial records were seen and found to be accurately maintained and corresponded with monies held for safekeeping. Only the administrator and the managers have access to residents’ cash. Housekeeping accounts were seen. The Manager shops locally and food is delivered from various trades people including the butcher, fruit and veg and bread and milk suppliers. The budget for the home including food and provisions was discussed with Mr Beale, the owner. Recording systems are effective and clear. the accident book had been completed correctly and in keeping with data protection. All residents’ confidential files are held securely. The health, safety and welfare of residents is assured by the systems in place and management of the home, and the caring approach and attitudes of the staff as seen during the inspection. Equipment is tested regularly, either by the handyman or by contractors, according to the guidelines and regulations including electrical and gas, water, lifts, hoists and wheelchairs. The Fire logbook and fire plans showed records of checks and tests to systems and equipment as recommended by the Fire Safety Officer. The Fire Safety risk assessment included the evacuation plans for residents in keeping with their care plans. Windows have restricted openings on the upper floor. The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 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 3 4 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 x 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 4 2 3 3 3 3 4 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 4 x 3 3 3 3 3 The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 19 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 21 Regulation 12(4)(a) Requirement All bathroom/toilet doors must be fitted with appropriate locks that can be overriden to allow staff entry in the event of an emergency. Timescale for action 1st september 2005 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 Good Practice Recommendations The Manor House D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 D52-D04 S60572 The Manor House V222419 160605 Stage 4.doc Version 1.30 Page 21 - 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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