Inspection on 30/08/05 for The Manor House

This inspection was carried out on 30th August 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 04/09/07

The Manor House 05/12/06

The Manor House 20/02/06

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 Announced 30 August 2005 9:15am 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 E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 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 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 Phyllis Jean Smith CRH 33 Category(ies) of DE(E) - 6 registration, with number OP - 33 of places The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 24 January 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 is currently in the process of being landscaped for the benefit of the residents. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced visit was made on the 30th August 2005 at 9.15am. The inspection was carried out by one inspector using 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 7 hours. The registered care manager, Jean Smith was present throughout the inspection. The senior carer was in charge of the home on that day plus a care assistant from 8.00 a.m. to 8.00 p.m. and 3 further care assistants from 8.00 a.m. to 2.00 p.m. 3 care assistants were on duty from 2.00 p.m. to 8.00 p.m. and a kitchen orderly was on duty from 3.00 p.m. to 7.00 p.m. Night duty was covered by 3 care assistants on duty from 8.00 p.m. to 8.00 a.m. and on call provision each night from either the registered care manager or the senior carer. Other ancillary staff on duty that day were: a cook, a kitchen assistant, a kitchen orderly, 2 domestics, and a maintenance person. There were 26 residents living within the home and these staffing levels were deemed as satisfactory to meet the needs of those residents. The inspection included a tour of the home, inspection of records, observation and discussions with residents, the care manager and other staff. Since the last inspection on 24th January 2005, one complaint had been received by the Commission and was in the process of being investigated at the time of the inspection. No incidents or reports of abuse of any kind had been received and no requirements or recommendations, against the regulations or the minimum standards, were outstanding from the last inspection report. The pre-admission assessments were carried out by the registered care manager or the senior carer and residents and their relatives were invited to visit the home for lunch and/or to have a look around to see if the home was right for them, once it had been assessed that the home could meet the needs of the individual. All aspects of health and personal needs were addressed to a good standard and recorded accordingly. However, social care requirements should be more detailed in the care plans. Residents spoke highly of the standard of care provided by Jean Smith and the staff within the home and confirmed that they were treated with dignity and respect. The home was generally well maintained and fit for purpose. Internally, the Manor House was a comfortable and homely environment for the residents and was very clean, warm and tidy. The fixtures and fittings were of a good The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 6 standard and all bedrooms contained a range of resident’s personal furniture and other individual items. The lounges and dining rooms were decorated to a high standard and provided a ‘home from home’ environment for the benefit of the residents. Externally, a number of residential properties were in the process of being built at the front of the home and some residents commented about the loss of the view. A small seating area was available at the front of the home but this was not ideal in terms of being directly in front of the building site. However, at the rear of the home, further building work was taking place to replace the existing staff room, extend the manager’s office and create an accessible garden area for the residents. It is understood by the inspector that this garden will be a safe, attractive and accessible area for the residents once completed. Jean Smith had worked in the care industry for a number of years and is an experienced manager. All staff had received training in the protection of vulnerable adults and good robust systems were in place to safeguard resident’s health, safety and welfare. What the service does well: What has improved since the last inspection? What they could do better: Two requirements and one recommendation were raised as a result of this inspection: to carry out risk assessments on all residents who have a bed rail in place, and on a large window in the double bedroom to ensure the continuing safety of the residents in the home. It is required that this window be restricted before a resident moves into the room. The recommendation was for social needs to be more detailed in the individual care plans for each resident. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 7 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 E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 8 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 E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 9 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) 3 and 5 The care manager or the senior carer met with all prospective residents to carry out pre-admission assessments to identify their needs and to assure them that those needs could be met. Trial visits were offered to enable residents and relatives to make an informed choice about the home. EVIDENCE: The registered care manager or the senior carer carried out pre-admission assessments for all potential residents. Inspection of records evidenced a thorough, detailed assessment of needs including personal care, social history etc. Documentation and discussion with the care manager confirmed that prospective residents were able to visit the home for a meal before moving in and trial periods were offered for the first 4 to 6 weeks. One relative who had been visiting his wife in for respite, was also given lunch. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 10 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, 9 and 10 The care planning processes were well documented, thorough and enabled staff to have a clear understanding of resident’s needs. All health care needs were met and residents had access to a range of health professionals. Medication policies and procedures ensured the protection of the residents. Residents were treated with dignity and respect. EVIDENCE: Two individual plans of care and associated documentation were examined and were seen to be detailed and enabled staff to have a good understanding of resident’s needs and how those needs should be met. They included all aspects of health and personal care, but it is recommended that social care needs are set out in the care plan to ensure all types of need are being met at all times. Each care plan also included a photograph of each resident, a preadmission assessment and a contract signed by the resident. All care plans were reviewed monthly and risk assessments were completed in detail in most cases and reviewed monthly also. However, a risk assessment had not been completed for one resident who had rails attached to his bed and it is a requirement of this report that an audit of risk assessments for bed rails be undertaken to ensure that all residents who have bedrails have a risk assessment in place for their use. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 11 Residents had access to a range of health care specialists including the GP, district nurse and chiropodist, whose visits were recorded on each file. The district nurse was in attendance at the home on the day of the inspection. The Medication Administration Records and the Controlled Drug Register were examined and found to be accurate and authorised appropriately. Medicines were stored within a locked trolley and cupboard and provided a safe and secure environment for the storage of medicines including controlled drugs. Staff were observed knocking on bedroom and bathroom doors before entering and residents confirmed that they were treated politely and respectfully, and their privacy was upheld. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 12 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 and 15. Social, religious and recreational opportunities were available to satisfy the expectations of the residents within the home. Relatives and visitors were welcomed and residents were supported and encouraged to maintain contact with family and friends. Dietary needs of the residents were catered for and meals were well presented and nutritious. EVIDENCE: A selection of recreational activities was available for the residents, both in the home, at Autumn House Nursing Home on the same site and in the local community. These included: regular visits by an entertainer playing the keyboard and singing, armchair aerobics, a hairdresser, dominoes, bingo, card games, quizzes, crafts, reminiscence boxes and barbeques. In addition, residents had trips out to local amateur dramatic theatre productions, Llandudno, the Gatehouse Theatre, local pubs for bar meals and a drink, and into Stone town centre for shopping trips. Birthdays and special events were also celebrated. Religious needs were catered for and visits to the Home by the local clergy took place regularly. A Holy Communion service was held each month. Two residents visited St Michael’s Church every Sunday. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 13 The care manager and residents confirmed that there was an open visiting policy at the Home for relatives and friends and residents told the inspector that they were able to see them in their own rooms if they so wished. During the inspection, the inspector examined the catering records in the kitchen. Fridge, freezer and food probe temperatures were recorded in the diary and found to be correct. Weekly menus were examined and seen to be varied with choices available at mealtimes. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 14 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 and 18 The home had a satisfactory complaints procedure and residents were listened to and their comments acted upon. Residents were protected from abuse by the home’s Adult Protection procedure and training sessions on the protection of vulnerable adults. EVIDENCE: The Commission had received one complaint since the last inspection and this was in the process of being investigated at the time of the inspection. Residents confirmed that they did not have any complaints, one resident told the inspector ‘I am one very satisfied customer, and I don’t have any complaints’. When asked, residents were clear that if they had any complaints, they would be happy to tell the staff who they thought would ‘sort them out’ in a positive way for them. The home had a comprehensive complaints policy displayed in reception for the benefit of residents and relatives. The home had an Adult Protection procedure and a booklet, ‘Protection of Vulnerable Adults – guidelines for staff’ was given to all new staff as part of their induction. This was a good example of the home’s commitment to protecting residents from the risk of abuse. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 15 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 and 24 Internally, the home provided a well-maintained, homely environment throughout and residents had access to a number of comfortable, communal areas which were bright, warm and very clean. Externally, communal facilities were limited but a new garden area at the rear of the home was in the process of being completed which should provide a safe, attractive area for the residents to enjoy outdoors. Bedrooms were individually personalised and well maintained. EVIDENCE: The location and layout of the home was suitable for the residents and in close proximity to Stone town centre. The home was well maintained and comfortable providing a home from home environment for the benefit of the residents. However, at the front of the home, major building work was taking place where a number of residential homes were in the process of being completed. The front of the home was separated from this building site by fencing for the safety of the residents. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 16 There was a small area at the front of the home, near the fencing, where garden tables and chairs had been placed to provide the residents with the opportunity to sit outside. This was not ideal in terms of the possible noise and dust from the building site but at the time of the inspection, no other outdoor facility was available at the Manor House. However, at the rear of the home, the existing staff room had been removed and was in the process of being rebuilt in addition to an extension to the manager’s office. Also, a garden area accessible to the residents was being created. The inspector had a discussion with the registered provider and the site manager about this area for the residents, who confirmed that the garden would be safe, attractive and accessible to the residents once completed. The inspector will monitor this situation over the coming weeks. Internally, the home had three lounges which were all decorated to a high standard with good quality carpeting and a variety of domestic furnishings and fittings. Each room had some of the following: a television, CD player, an organ, books, specialist chairs, footstools etc and was homely, comfortable and very clean. The dining rooms were similarly decorated to a good standard, comfortable and set out to provide a ‘home from home’ experience for the residents. The tables were laid with tablecloths and soft music from the radio was playing during mealtimes. The home had 29 single bedrooms and 2 double bedrooms – 1 with an en-suite and most were decorated to a good standard. Bedrooms were personalised with individual resident’s furniture/possessions and contained a locked drawer facility for the safekeeping of valuables if required. Wardrobes were restricted, radiators were guarded and smoke detectors were in situ in each room. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 17 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 and 29 Staffing at the home was satisfactory to meet the needs of the residents. The recruitment and selection procedures operated within the home were thorough, robust and well documented for the protection of the residents. EVIDENCE: On the day of the inspection, the registered care manager was in attendance plus a senior carer on duty all day, plus a care assistant from 8.00 a.m. to 8.00 p.m. and 3 further care assistants from 8.00 a.m. to 2.00 p.m. 3 care assistants were on duty from 2.00 p.m. to 8.00 p.m. and a kitchen orderly was on duty from 3.00 p.m. to 7.00 p.m. Night duty was covered by 3 care assistants on duty from 8.00 p.m. to 8.00 a.m. and on call provision each night from either the registered care manager or the senior carer. Other ancillary staff on duty that day were: a cook, a kitchen assistant, a kitchen orderly, 2 domestics, and a maintenance person. There were 26 residents living within the home and these staffing levels were deemed as satisfactory to meet the needs of those residents. Two staff files were examined and a thorough recruitment and selection process was in place, and included all required elements such as CRB clearances, references etc. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 18 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, 33, 36 and 38. The registered care manager was experienced in providing care for the elderly and fully committed to meeting their needs. Residents and relatives were encouraged to provide feedback to enable effective audit of the service provided. Staff supervision sessions took place to enable staff to contribute to service delivery. The safety of the residents would be enhanced if upstairs windows were restricted. EVIDENCE: Inspection of records, discussion with the registered care manager and observation of the positive interaction between her and the residents evidenced that she was experienced and competent to run the home. She had an informal management approach which was open, approachable and positive creating a relaxed and inclusive atmosphere within the home. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 19 The care manager’s commitment to the residents was evident throughout the inspection. One resident made the comment that she had missed seeing the care manager due to her time taken up with the inspection that day! The inclusive approach by the care manager included an annual questionnaire for residents and relatives, and feedback had been analysed and used accordingly. Staff supervision records were inspected and included all aspects of care. In addition to this, annual appraisals took place for all staff. During the tour of the home, the inspector noticed that the large window in the double room was able to open fully and although the room is currently empty, it is a requirement of this report that a risk assessment is carried out on the window in the double bedroom and for the window to be restricted before any resident moves into the room to ensure ongoing protection of the resident. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 20 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 x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 x x x 3 x x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x 3 x 2 The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 21 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. 2. Standard OP 7 OP 38 Regulation 13 (4)(c) 13 (4)(c) Requirement To ensure that all residents who have bedrails have a risk assessment in place. To carry out a risk assessment on the window in the double bedroom and for the window to be restricted to protect the safety of any resident moving into the room. Timescale for action Immediate 31/10/05 or earlier if room is to be occupied. 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 OP 7 Good Practice Recommendations Social care needs to be set out in the care plan to ensure all types of need are being met at all times. The Manor House E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Stafford - 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 E51-E09 S5017 Manor House V240844 300805 Stage 4.doc Version 1.40 Page 23 - 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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