Inspection on 23/02/06 for The Manor House

This inspection was carried out on 23rd February 2006.

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 16/06/05

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 Devon PL6 5JE Lead Inspector Sheila Giblin Unannounced Inspection 23rd February 2006 09:30 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 DS0000060572.V284148.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 DS0000060572.V284148.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Manor House Address 135 Looseleigh Lane Derriford Plymouth Devon PL6 5JE 01752 778280 01752 778280 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) 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 DS0000060572.V284148.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 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 DS0000060572.V284148.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over five hours on the morning of 23rd February 2006. The Registered Manager was on duty and the admin officer assisted the inspection by providing records and documents as requested. The inspector saw all 28 residents in the home and met and talked to 18 in their own rooms, in the lounge and in the dining room. Comments were sought from people visiting the home and these included the chiropodist, a relative and a friend of service users. There were five care staff on duty plus a domestic assistant and the chef. What the service does well: What has improved since the last inspection? What they could do better: Mrs Daw is always looking to improve the services being provided. Plans are in hand to refurbish 3 or 4 bathrooms during which time the locks on all the bathroom doors will be changed to allow them to be over ridden by staff if necessary during an emergency. The Manor House DS0000060572.V284148.R01.S.doc Version 5.1 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 DS0000060572.V284148.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 DS0000060572.V284148.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, 3, 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: Every resident applying for a place in the Manor House is assessed by the manager before admission. 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 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. 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 DS0000060572.V284148.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, 9, 10 Residents can be confident that their health and care needs will be met in a respectful way. EVIDENCE: Residents’ records showed evidence of GP and Community Nurse input. The visiting chiropodist 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. Everyone who spoke to the inspector said that they were treated with the utmost respect and dignity. During the inspection the manager was involved in discussions with a GP and a Consultant regarding the mental health of a resident and the admission to hospital for treatment was being arranged. The administration of medication was inspected and found to be in order. The home uses a monitored dosage system in blister packs. The supplies were securely stored in a metal trolley and a metal cupboard. No controlled drugs were in use in the home at the time of this inspection. The home has a list of homely remedies from the NHS. There were records of receipt and disposal of residents’ prescribed medicines. The medication administration records held a photograph of each resident to receive medication. All the records were The Manor House DS0000060572.V284148.R01.S.doc Version 5.1 Page 10 accurately completed. Mrs Daw the manager usually administered medication. This serves two purposes in that she sees everyone every day besides administering their medication. Specimen signatures were on file of those senior staff permitted to administer medication in her absence: those staff who had completed the 12 week training course ‘Safe Handling of Medications’. The Manor House DS0000060572.V284148.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): 12, 13, 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. 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 and the inspector saw residents enjoying a sing a long and a game of bingo. Other activities include quizzes and reminiscence, karaoke and music, physical exercise and games provided weekly and fortnightly. Residents are encouraged to go out on trips 3 or 4 times a year in small groups to local places of interest and beauty spots for a cream tea. Some residents go out with their family and friends. A residents’ meeting had been arranged for Monday 27th February. Each resident had been notified of this by poster which had been delivered to their rooms. Lunch was served during the inspection. The inspector sat with residents and noted their satisfaction with the generous portions and offers of second helpings. 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 mealtime 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 DS0000060572.V284148.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 Residents and their relatives can be confident that any complaints they make will be taken seriously and acted upon promptly. EVIDENCE: One complaint has been received by the Commission and forwarded to the home for investigation and attention. Records were viewed and the correspondence sent out was noted to be in keeping with the home’s complaints policy and procedures. The manager was awaiting the response from the complainant to see if they were satisfied with the outcome. 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 in the Complaints Book no matter how small and uses the information to constantly review services and make improvements if necessary. The Manor House DS0000060572.V284148.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): 19, 20, 21, 22, 23, 24, 25, 26 Residents live in a well maintained home that is warm, comfortable, safe and secure. 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. The gardens are easily accessible from the house. They have been laid out to offer walkways and seating areas for residents and their visitors. Many of the rooms overlook the gardens and residents said how much they enjoyed looking at the trees, birds and squirrels to be seen there. Seventeen bedrooms have an en suite toilet. There are five bathrooms located around the home and a shower room on the ground floor. Three or four bathrooms are to be refurbished and upgraded which will ensure that appropriate locks that can be overridden by staff in the event of an emergency will be installed. All residents’ bedrooms were pleasantly decorated, comfortably furnished and were personalised with their own pictures and The Manor House DS0000060572.V284148.R01.S.doc Version 5.1 Page 14 ornaments. Residents said that staff always knocked on the door before entering. 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. Temperature regulation valves ensure hot water temperatures are regulated to avoid the risk of scalding. The home was spotlessly clean throughout. No offensive smells were detected anywhere. The home’s laundering and cleaning equipment has been purchased to ensure the risk of cross infection is minimised and the carpets retain their freshness. The Manor House DS0000060572.V284148.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): 27, 28, Residents can be confident that their care needs will be met by a group of kind staff who are knowledgeable and capable. EVIDENCE: The staff team is led by the Registered Manager and is made up of a deputy manager, senior carers, care assistants, domestic assistants, cooks, gardener and a 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. A junior office apprentice has started training under the guidance of the admin officer. All the residents said they liked the staff and had confidence in them to look after them properly. Staff were seen working and talking with residents appropriately. Over 60 of staff hold the NVQ2 Certificate. Medication training has been completed by means of a 12 week correspondence course followed by a practical assessment. Fifteen staff have a first aid certificate. The Manor House DS0000060572.V284148.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): 31, 32, 33, Residents can be confident that the Manor House is well managed and organised to be able to meet their needs and keep them safe. 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 during 2006. Mrs Daw has managed The Manor House for 7 years. The deputy manager has started NVQ4 in care management. The atmosphere in the home was lively and positive. Staff and residents commended the manager for her professional approach and kindness. Evidence of this was seen when a resident came to the office and asked for assistance in sorting out a personal problem. 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. A residents’ meeting had been arranged for the 27th February 06. The Manor House DS0000060572.V284148.R01.S.doc Version 5.1 Page 17 The accounting and financial procedures in the home are managed by the administrator and audited by the owners monthly. 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. Windows have restricted openings on the upper floor. The Manor House DS0000060572.V284148.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 3 X 4 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 X 4 4 2 3 3 3 3 4 STAFFING Standard No Score 27 3 28 4 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X X X X X The Manor House DS0000060572.V284148.R01.S.doc Version 5.1 Page 19 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 OP21 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 01/07/06 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 DS0000060572.V284148.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Ashburton Office 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 DS0000060572.V284148.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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