Inspection on 30/11/05 for The Manor House

This inspection was carried out on 30th 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Manor House 07/08/07

The Manor House 24/08/06

The Manor House 06/07/05

The Manor House 25/10/04

The Manor House 08/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 The Manor House Whitton Road Alkborough Scunthorpe North Lincolnshire DN15 9JG Lead Inspector Janet Lamb Announced Inspection 30th November 2005 09:30 The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 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 DS0000002816.V265162.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 Adults 18-65. 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 DS0000002816.V265162.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Manor House Address Whitton Road Alkborough Scunthorpe North Lincolnshire DN15 9JG 01724 720742 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) Prime Life Limited Ms Shirley Dawson Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can only accept the specified service users, Mr RS and Mr PB, over the age of 65 years. 6th July 2005 Date of last inspection Brief Description of the Service: The Manor House is a large property in its own grounds in the village of Alkborough, providing care and accommodation to up to 12 adults with learning disability. There are single and double bedrooms on the ground and first floor and there is plenty of space within communal areas for residents to use. The home has a mini bus, gardens with roaming fowl, and a courtyard for service users to use at will. A local village shop is within walking distance, and the town of Scunthorpe is a short bus ride away. The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection, one of two required in each inspection year, took place over two visits and took approximately 7½ hours to complete. The inspection involved speaking to service users, staff and the Manager, viewing some of the communal areas of the home, and inspecting some of the records and documents held there. What the service does well: 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 DS0000002816.V265162.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgement was made in this section. EVIDENCE: No evidence was gathered against outcomes in this section. The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 only. Residents take risks with staff support, in pursuit of an independent lifestyle. EVIDENCE: Residents lead independent lives wherever and whenever possible, and join in with activities and pastimes that may involve an element of risk. This is only done, however, within the guidelines of a written risk assessment document held on file and only if the risk can be reduced. Residents talked a little about the activities they engage in, and they were observed being supported by staff offering advice and information about the nature of the risks involved in going places or doing things. Staff also accompanied residents when they left the building. Some residents were out for the day at activities and occupational placements. Unfortunately they were unable to be consulted about the risks they take, but information from the Manager and staff revealed residents take risks in maintaining their independence, but receive every necessary support from the staff and other agencies or services involved. Documents and records are held on files. The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13. Residents have good opportunities to take part in age, peer and culturally appropriate activities in the local community or in Scunthorpe town centre. EVIDENCE: Residents spoken to informed the Inspector they enjoy a variety of pastimes in the home and community, including such as swimming, shopping, baking, walking, gardening, craftwork, television, music, and patronising Alkborough Club in the village. Plans are being organised for individual residents to attend gentle aerobics, fishing and horse riding. Work and occupational placements are also being explored, to include for example hairdressing, and will be sought after residents have undertaken an eight-week Mencap Pathway Course. Two residents are already doing the Pathway Course. Residents take walks around the village and visit the local shop. Records of their activities are held on file. The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 only. Residents are well protected by the home’s policies, procedures and practices for administering medication, but none are retaining, administering or controlling their own medication at the moment. EVIDENCE: Some residents were observed taking responsibility for the timely administering of their medication, while others relied upon staff. No one selfmedicates in the home at the moment, but they are well protected by the staff practices for handing out medicines. Staff have received company-organised training in medication administration, and all but three staff are competent to give out medication. These three have been instructed in awareness of safe handling of drugs and would only give out medicines when overseen by the Manager or Deputy. The home currently uses the Nomad Monitored Dosage system, but the supplying pharmacist does not have sufficient cassettes to provide the service properly. The Manager is in the process of taking the matter up and is likely to change to another system. The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 11 Practice within the home is as safe as it can be, and the Manager is extra vigilant when receiving the weekly cassettes into the home. A safe medication handling and administration trail is followed, based on clear policies and procedures, and backed up by consistent and accurate records. The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgement was made in this section. EVIDENCE: No evidence was gathered against outcomes in this section. The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgement was made in this section. EVIDENCE: No evidence was gathered against outcomes in this section. The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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 and 34. Residents are well supported by staff, half of which are qualified and all of which are considered to be competent and trained. Residents are satisfactorily protected by good recruitment practices. EVIDENCE: Residents spoken to were not especially concerned with staff training and qualifications, but they were interested in how well staff supported them and assisted them throughout the day. Staff were observed providing advice, comfort and practical help. Of the 14 staff employed in the home 7 have completed or are doing NVQ level 2, one is also doing level 3. Another staff member has a degree in Health and Social Care. This brings the percentage of staff with the required qualification to 57½ , and therefore meets requirements of the standard. Recruitment and selection of staff follows the policy, procedures and practice of Prime Life Ltd, and evidence seen in two staff files shows the home complies with schedule 2, and Criminal Records Bureau checks. The home also maintains a staff register in which main details and a photograph are held. The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Residents benefit fairly well from a well run home where their views are used to inform management for the future development of the service provided, and where their health and safety are adequately promoted and protected in all but two areas. EVIDENCE: The Manager has almost completed the NVQ level 4 Registered Manager’s Award. She has a job description and undertakes training to maintain a good knowledge base and to stay ahead of trends and systems within caring. There is a tentative quality assurance system in place, which involves surveying of residents and their family members, and which is intended to meet the requirements of the North Lincolnshire Council ‘gold award’ scheme. The quality assurance system recently began with a survey of the care plan review system within the home and as a result has improved the level of independence for residents in respect of the way reviews are organised. The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 16 Once the quality assurance system has reached the end of a cycle and a review of the system has been carried out, the CSCI must receive a copy of the review report, as in regulation 24. This regulation is expected to be met within the next 6 months and observation of residents’ interaction with staff and management reveals they are confident their views and plans for their future are listened to on a daily basis. Evidence in the form of the review report must be received within 6 months, if this standard outcome is to remain scored as met. The Manager and staff maintain equipment, systems and services throughout the home to ensure safety and welfare of residents. There are policies and procedures in place, guidelines to follow and training for staff in the appropriate areas of health and safety. Safety records and monitoring documents are held, along with risk assessment documents. Fire safety checks are made and drills held regularly as required, new detection equipment is in place, new fire doors and self-closing devices are in place, a risk assessment is available, and residents and staff have new instructions to follow in the event of contacting management in an emergency. All other safety measures and documentation to evidence them are in place, with the exception of a current electrical wiring safety certificate and evidence of a current legionella check on the water storage system. The Manor House DS0000002816.V265162.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Manor House Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000002816.V265162.R01.S.doc Version 5.0 Page 18 Yes. 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 YA5 Regulation 5 Requirement The Registered Provider must develop a contract that meets the requirements of standard 5 and regulation 5. (This is a continuing requirement.) The Registered provider must ensure the home has a current electrical safety certificate following an electrical safety check completed by an approved electrician. The Registered Provider must ensure the water supply system is checked for the presence of legionella and a certificate/statement to that effect should be held in the home. Timescale for action 28/02/06 2 YA42 13(4) and 23(2)(p) 31/01/06 3 YA42 13(4)(c) 31/01/06 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 DS0000002816.V265162.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000002816.V265162.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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