Inspection on 20/02/06 for The Manor House

This inspection was carried out on 20th February 2006.

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

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

Other inspections for this house

The Manor House 04/09/07

The Manor House 05/12/06

The Manor House 30/08/05

The Manor House 24/02/05

The Manor House 05/07/04

The Manor House 03/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Manor House, 37 Stafford Road Walton Stone Staffordshire ST15 0HG Lead Inspector Lynne Gammon Unannounced Inspection 20th February 2006 09:00 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 House, DS0000005017.V280989.R01.S.doc Version 5.1 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 House, DS0000005017.V280989.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Manor House, Address 37 Stafford Road Walton Stone Staffordshire ST15 0HG 01785 812885 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) Mr Richard Charles Britten Mrs Diane Isobel Britten Mrs Phyllis Jean Smith Care Home 33 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (33) of places The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2005 Brief Description of the Service: Located on the periphery of the town of Stone, the Manor stands on the complex known as Waverley Homes. Registered to provide accommodation for thirty-three older people, some of whom may have a physical disability, some of which may have a mental frailty. The home was extended some years ago; part of the home retains some of its original features. Within the home are three lounges, two dining rooms; one of each located on the first floor. Access to the first floor can be gained via the shaft lift or the stairs at both ends of the home. Bedrooms with the exception of two are for single occupancy. The rear garden has recently been landscaped for the benefit of the residents. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was made on the 20th February 2006 at 9.00 am. The inspection was carried out by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 6 hours. The inspection included a part tour of the building, inspection of records, observation, and discussions with service users and staff. What the service does well: What has improved since the last inspection? Redecorating had taken place in a number of bedrooms and a new French door put in place in one of the lounges. New carpet had been laid in some bedrooms and new curtains purchased for the French doors. A new conservatory/staff room had been built and the manager’s office had been extended. The rear garden of the home had been landscaped and was easily accessible to the service users. No requirements or recommendations were outstanding from the previous inspection. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 Page 6 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, DS0000005017.V280989.R01.S.doc Version 5.1 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 House, DS0000005017.V280989.R01.S.doc Version 5.1 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 the following standard(s): 1, 2 and 4. The Statement of Purpose and Service User Guide were in the process of being updated. A contract was in place for service users and they received written confirmation that their needs could be met prior to moving into the home. EVIDENCE: The Statement of Purpose and Service User Guide were examined and were in the process of being amended and updated. Most of the required elements were contained within the documents, however, there were a few omissions such as fire precautions and associated emergency procedures etc. It is a requirement of this report that the Statement of Purpose and Service User Guide is amended to include all elements of Schedule 1 of the Care Homes Regulations 2001. A contract was inspected and included details of fees, services included within the fees, those items/services not covered by the fees, termination, etc. A standard letter, which was used to inform potential service users that the home could meet their needs, was very clear and self-explanatory. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 11. Care planning processes within the home provided staff with sufficient information to meet service user’s needs satisfactorily. Health care needs were met very well and service user’s needs at the time of their death were treated with dignity and respect. EVIDENCE: Service user care plans were examined and found to provide a range of information about activities of daily living. Each care plan was reviewed monthly and risk assessments were completed and also reviewed monthly. The daily report was completed and provided an up-to-date picture of the current status of the individual service user. Access to other health care professionals was recorded and evidenced that service users health care needs were met well. One service user who had been admitted to the home following hospital admission for a fractured arm was very complimentary about the health care provided and the support that she had received from staff to help her build her confidence again. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 Page 10 One of the care plans evidenced that a service user wished to leave any funeral arrangements to her family when the time came, others had pre-paid for their funerals and these details were included in their care plans. It was clear from this information that staff made every attempt to meet the wishes of the service user, at every stage of their life. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. All other key standards were examined at the last inspection on 30th August 2005 and were met well. Service users were supported to make their own decisions and choices in their everyday lives. EVIDENCE: Observation and discussions with service users evidenced that they were able to make their own choices in their day-to-day lives and staff respected their rights. Good interaction was observed between service users and staff and the home had a relaxed atmosphere where people were encouraged to continue with their individualised lifestyle. Two service users who were admitted to the home for short term-care were very pleased with their progress and improvements in their independence since their admission to the home. Documentation evidenced that the home worked closely with the Re-ablement team to assist the service user’s progress. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 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 the following standard(s): 16, 17 and 18. A satisfactory complaints procedure was in place and service users felt that they were listened to and action was taken to resolve their issues. Service users were supported and enabled to participate in the electoral process and were protected from abuse by the home’s Adult Protection procedure and training on abuse awareness. EVIDENCE: Both the Commission and the home had not received any formal complaints since the last inspection. Service users confirmed that they did not have any complaints but if any complaints were raised, they felt that staff would make every attempt to resolve them as far as possible. The registered care manager confirmed that service users were able to take part in the electoral process by postal vote if they so wished. If any service user wished to visit an election polling station, staff or relatives supported this. There had been no incidents or allegations of abuse received by the home or the Commission for Social Care Inspection and the home had an Adult Protection procedure to ensure the protection of the service users. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 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 the following standard(s): 21, 22, 23, 25 and 26. Satisfactory toilet and washing facilities were available for the service users and a range of specialist equipment was provided to support independence. Rooms were suitable to meet needs and the home provided a safe, comfortable and clean environment for the benefit of the service users. EVIDENCE: There were adequate toilets and washing facilities within the home which were clean and uncluttered. Adaptations had been made to the home and specialist equipment provided to promote and maintain independence. The layout and dimensions of bedrooms were adequate to meet the needs of the service users and contained smoke alarms and covered radiators with emergency lighting evident throughout the home. The home was extremely clean and homely throughout. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 Page 14 Some bedrooms had been redecorated and had new carpet laid in them. New French doors had been put in one of the lounges with direct access to the new patio area at the rear of the home. New curtains had been purchased for the French doors also. A new conservatory/staff room had been added to the home and the manager’s office had been extended. The rear garden of the home had recently been landscaped with a central fountain as the main feature of the garden. A risk assessment had been completed for the fountain. Some shrubs had been planted in raised beds, with garden lights and seating in place for the benefit of the service users. Some final work was required to complete the garden and gates were due to be put in place to ensure the safety of the service users. It was anticipated that building work at the front of the home would be completed by the end of March 2006. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 30. Service users were cared for by qualified staff that were competent and trained to carry out their jobs. EVIDENCE: Discussion with the registered care manager confirmed that the home currently had 18 care staff working in the home with 2 having achieved NVQ Level 2 in care, 4 with NVQ Level 3 in care and the manager and deputy manager with NVQ Level 4 in care. In addition to this, 1 care staff member was in the middle of completing NVQ Level 2 in care and another was about to start NVQ Level 3 shortly. Once they had completed this training, the home would exceed the required 50 of trained members of staff with NVQ level 2 or above working in the home. The records detailing the type and frequency of training undertaken by the staff within the home was examined and evidenced that mandatory training had taken place plus a range of other training such as: basic food hygiene, helping clients with feeding and swallowing, foot health and hygiene etc. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 37 and 38. The home was well managed and the service users benefited from an open and friendly management style. Financial procedures were robust to protect service user’s financial interests. Records were accurate and up-to-date and policies and procedures were reviewed regularly to safeguard the best interests of the service users. EVIDENCE: The processes for running and managing the home were open and transparent. Regular staff meetings took place and staff were able to contribute and affect the way in which the service was delivered. Minutes for all staff meetings were taken and copied for staff. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 Page 17 Financial procedures and processes were examined and records of service user’s personal allowances were examined and found to balance with monies held. Records for the protection of service users, individual records and home records were seen to be secure, up to date and in good order. Policy and procedural documentation was examined and it was noted that these were reviewed regularly and evidenced in staff records that these were discussed with staff at supervision. A range of records and documentation was examined and provided evidence that the health, safety and welfare of service users and staff were protected. Fire safety records showed that the fire alarm and fire extinguishers were tested on 10/02/06 and the annual service for the fire extinguishers took place on 06/02/06. Other records included: gas safety check on 01/08/05, a lift service on 17/02/06, Bath hoist serviced on 15/11/05 etc. An electrical installation inspection certificate was not available during the inspection, however, rewiring was taking place within the home and a copy of this would be provided to the Commission once completed. A water test for Legionella had not been undertaken for some time and it is a requirement of this report that this is carried out as soon as possible. The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X 3 3 3 X 3 3 STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 3 X 3 2 The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 (1)(c) Requirement For the Statement of Purpose and Service User Guide to include all elements of Schedule 1 of the Care Homes Regulations 2001. For water tanks to be tested for Legionella as soon as possible. Timescale for action 30/04/06 2. OP38 13 (4)(c) 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Manor House, DS0000005017.V280989.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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, DS0000005017.V280989.R01.S.doc Version 5.1 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. 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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