Inspection on 29/11/05 for The Manor House

This inspection was carried out on 29th November 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 20/04/09

The Manor House 02/05/07

The Manor House 08/09/05

The Manor House 15/03/05

The Manor House 20/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Manor House North Walsham Wood North Walsham Norfolk NR28 0LU Lead Inspector Mrs Geraldine Allen Announced Inspection 29th November 2005 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 DS0000027287.V260219.R01.S.doc Version 5.0 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 DS0000027287.V260219.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Manor House Address North Walsham Wood North Walsham Norfolk NR28 0LU 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) 01692 402252 01692 402252 The Manor House (North Walsham Wood) Limited Mrs Pamela Mary Davis Care Home 52 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (42) of places The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: The Manor House is a care home providing personal care for up to 52 older people. The home is owned by The Manor House (North Walsham Wood) Limited. The home is located close to the market town of North Walsham, with all the usual amenities, and is set in 18 acres of gardens and woodland, all of which are accessible to residents. There are also bird aviaries within the grounds. The home provides accommodation in 45 single bedrooms and 3 shared bedrooms. Most of the bedrooms have en-suite facilities. Residents’ accommodation is located on the ground and first floors. There is extensive communal space in the home including a conservatory, dining room, lounge, lounge/diner and library. Assisted bathing facilities are situated throughout the home and assisted passage between floors is via a shaft lift. The home has extensive, well-maintained grounds and there is ample parking available. This home has won awards for its pet-friendly approach and this is well monitored. The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place during the day of 29 November 2005. On the day of inspection there were 48 residents present. The purpose of this inspection was to consider the experience for residents who live at The Manor House and to see if it met their expectations and preferences. Prior to the inspection, the manager, Mrs Davis, completed and returned a preinspection questionnaire. Twenty-five completed comment cards were received from residents and 2 received from visiting health professionals. No questionnaires were received from relatives and visitors to the home. The home had very recently completed a satisfaction survey and the findings of this were used within the inspection report. Information was gathered during the inspection from several sources including, talking in private and in depth with residents and staff. Records were seen and a tour of the building was also done. Lunch was also eaten with residents as part of the inspection. The interaction between staff and residents was observed throughout the day and was seen to be appropriate and respectful. Residents were very open and chatty and spoke warmly about the staff. Residents used various expressions to describe the staff including “lovely” and “very kind and caring”. One residents said “Why would anyone want to live anywhere else?” This inspection found that this home provides high quality care in a very pleasing environment. Staff are caring and approachable and clearly enjoy their work and spending time with the residents. What the service does well: The home employs very good staff levels that allow for staff to spend quality time on a one-to-one basis with residents. This is something that is appreciated by residents and staff. Staff spoke of enjoying working at this home. Staff are also in receipt of appropriate and timely training that informs and supports them to fulfil their role. The staff spoken to at this inspection were keen to take the training opportunities offered to them. Residents enjoy very good food that is freshly prepared from fresh produce. The range of choices available were very good and the food was well The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 Page 6 presented. Residents thoroughly enjoyed their food and regarded mealtimes as a very sociable time of day. Residents receive good support from local healthcare services and the GP and District Nurses responded very positively to the Commission about the ability of the staff at this home to provide a high standard of care. 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 DS0000027287.V260219.R01.S.doc Version 5.0 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 DS0000027287.V260219.R01.S.doc Version 5.0 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): These standards were not inspected on this occasion. This home does not provide intermediate care. EVIDENCE: The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 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): 8 & 10 Residents have their healthcare needs met appropriately and in a timely manner. Residents stated that they were treated with respect and in a dignified way. EVIDENCE: Completed comment cards were received from a GP and District Nurse. Both confirmed that the home obtains timely advice and guidance when necessary. One stated, “The care manager and her staff liaise very well”. It was also confirmed that staff comply with any instruction from healthcare professionals. Residents spoke about the care and support they receive from staff when needed. Examples were given of how staff treat them with respect and kindness. All the completed comment cards received from residents confirmed they felt well cared for, respected and treated with dignity and in private when appropriate. One resident notated the comment card with “always” where asked if they were treated well. Another resident has added additional ticks at this question to denote a high level of satisfaction. The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 & 15 Residents have a lifestyle that matches their preferences and expectations. Residents are able to entertain their visitors when they wish and they are supported to access the local community as much as they can. Residents described the choices they are able to make in their daily lives and how staff respect them. Residents receive a well-balanced and nutritious diet that meets their needs. EVIDENCE: Residents spoke about how they can make choices in their daily lives and described how staff understood and respected the choices they make. During the course of this inspection, staff were observed offering choices to residents and abiding by the stated preferences. Residents said they felt able to entertain their visitors when they wished and that their visitors were made to feel welcome at the home. During the course of this inspection, 1 visitor was seen eating lunch with a resident. Later, 2 visitors were seen being welcomed by staff and a neatly laid tray of tea being provided. Visitors seen confirmed they were always made to feel welcome. The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 Page 11 During the course of the inspection, 1 resident was seen going out to lunch with her visitors. Time was spent talking with residents about their daily lives and the comments received were positive and complimentary of the staff at the home. Residents stated they could rise and retire when they wished. They also described spending time where and with whom they wished. Residents are also offered choices of meals. Lunch was eaten with 4 residents in one of the dining rooms. Residents said they had been asked what they would like from a range of options the afternoon before. Lunch was a 3-course meal that was enjoyed by those residents at the table. It was seen that their expressed choices were respected and special diets were provided for. Staff were available to provide support as needed. The food was freshly prepared using fresh produce. The quality was high and the presentation of a high standard. The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 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 & 18 The home has a complaints procedure that is displayed in the home and generally known to residents and visitors to the home. Residents are protected from abuse by good employment practice and trained staff. EVIDENCE: The home has a complaints procedure that is displayed and known by residents and visitors. Two complaints have been received by the home in the last 12-months and the records of these were seen. In both cases, the home had acted appropriately and in a timely manner. Staff spoken to had a good understanding of adult protection matters. The home has robust recruitment procedures in place that include obtaining Criminal Records Bureau and Protection of Vulnerable Adults (CRB/POVA) register checks. CRB and POVA checks were seen and appropriately stored. The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 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, 23, 24 & 26 The home is kept in a safe condition and is well maintained. Residents are able to access internal and external facilities in safety. Residents bedrooms are decorated and furnished to meet their needs and respect their choices and preferences. Residents bedrooms are highly personalised and contain many of the residents’ own belongings. The home is clean, tidy and free of unpleasant odours. EVIDENCE: The home is very well maintained and kept in a good state of décor. Environment risk assessments were seen during this inspection and they demonstrated a commitment to maintaining a safe environment. The home’s Asbestos Survey Report was seen and the arrangements to deal with 1 small The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 Page 14 area of asbestos were explained. This work will be complete by the time this report is available. Residents were seen throughout the home and grounds on the day of inspection. Residents have free access to all areas and they were observed enjoying both the internal and external environment. Level access to outside is available to assist those residents in wheelchairs and with limited walking. All communal areas are in good order and well maintained. Some residents bedrooms were seen during this inspection. They were well furnished and decorated. All bedrooms seen were of a good size and allowed residents to arrange their furniture as they wished. Each of the bedrooms seen contained furniture and features belonging to the resident. This resulted in a high level of personalisation. Residents clearly enjoyed being able to have significant personal items about them. Some residents also shared their bedrooms with their pets, including cats and dogs. Those areas of the home seen on the day of inspection were clean and tidy. No unpleasant odours were detected throughout the day. The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 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 & 30 Residents needs are met by the numbers and skills of staff employed at the home. Staff receive appropriate training and are competent to meet the needs of the residents. EVIDENCE: The staff rota for the week of inspection was provided. Calculations showed that the home employs staff in numbers that substantially exceed the minimum hours required for a home of this size. Mrs Davis stated that the staff levels are based on the resident’s needs and also the layout of the building. At least one senior carer is on duty between the hours of 07:00 and 22:30. All senior carers have obtained NVQ at level 3. In addition, the manager, Mrs Davis, or the deputy manager, Ms Gibbs (both registered nurses) are on duty or on call. Three waking night staff are employed between 22:30 and 08:00. Ancillary staff are also employed in good numbers. Mrs Davis stated that the home does not employ agency staff as the home has sufficient staff employed to be able to cover any absences from the home. Staff spoken to described the training opportunities that are available to them. All 3 staff spoken to in private were undertaking NVQ at either level 2 or 3. They also spoke about other training available to them and welcomed the opportunities to learn and develop their skills. Mrs Davis said that 3 care staff had now completed training in respect of activities. A senior carer and Mrs The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 Page 16 Davis, are also qualified manual handling trainers. Details of training either completed within the last 12 months, or planned for the next year were provided. The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 35, 36 & 38 The home is owned and managed by people who are fit and competent. Residents are able to live in a home that is run in their best interests. Staff understand the ethos and management approach at this home. Residents and their relatives are able to influence how the home is run and their views and opinions are sought. The home does not deal with resident’s finances. Staff are supervised but better recording needs to be considered. The health, safety and welfare of residents, staff and visitors to the home are protected by good practice and well-trained staff. EVIDENCE: The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 Page 18 The owners are fit to run The Manor House and have demonstrated over a significant period of time that the home is run to benefit the people who live there. The manager is well qualified and competent to undertake her role. Miss White and Mrs Davis are clear about the ethos and approach to care at this home. Staff understand their vision and feel supported in working towards this. Residents benefit from the approach to care and appreciate the way they are cared for and the staff attitude towards them. One resident stated: “Why would anyone want to live anywhere else?” Mrs Davis provided the summary from the last satisfaction survey conducted by the home. The summary showed the range of questions asked and the issues raised and how they were dealt with. A copy of the summary is displayed in the home. There was some discussion about future development of the satisfaction survey, including focusing on specific issues and also the range of people who may be approached for their views. The arrangements for the formal supervision and annual appraisal of staff were discussed with Mrs Davis. The records of staff appraisal were seen and included all the elements of best practice. Both parties signed the record and there was clear agreement about responsibility for any further action. Staff also receive supervision on a regular basis but this is not recorded. Supervision is taking place on a one-to-one and also group basis. The recording issues were discussed and ways to move this forward were considered. Mrs Davis stated that she would raise this matter at the next senior staff meeting, when a format would be developed and implemented for future use. This standard will be reviewed at the next inspection to assess progress made. A range of records regarding health and safety matters were seen during this inspection and were found to be up to date and in good order. The risk assessments for the environment were looked at and were clear and concise. All matters were up to date and sources for assessment and recording were based on recognised best practice. The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 Page 19 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 X 3 STAFFING Standard No Score 27 4 28 X 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 x N/A 3 X 3 The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 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. Standard Regulation Requirement 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. Refer to Standard Good Practice Recommendations The Manor House DS0000027287.V260219.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 DS0000027287.V260219.R01.S.doc Version 5.0 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!