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Inspection on 05/12/06 for The Manor House

Also see our care home review for The Manor House for more information

This inspection was carried out on 5th December 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The care planning processes were well documented and provided evidence of meeting a range of needs very well. When asked several residents stated that they were very pleased with the care that they received and were very satisfied at The Manor House. The home was found to be very clean and well maintained providing a warm, safe, homely environment for residents. The Inspector made several observations during this unannounced inspection and found that residents were appropriately supported and enabled to make choices and decisions about their own lives. Staff were trained and competent to undertake their jobs and good, robust systems were in place for the protection of service users. Financial and accounting systems were found to be thorough and correct. The gathering of information prior to the actual day of inspection including the following very positive comment that was recorded on a Relatives/Visitors Comment Card: "Each and every member of staff I have seen I can not praise highly enough. The home is spotlessly clean with no unpleasant odours. Each day to day problem concerning my relative is dealt with effortlessly and with understanding and compassion."

What has improved since the last inspection?

The landscaped garden and surrounding building work has been completed to a high standard and several residents commented positively about the attractive sitting area and waterfall.

CARE HOMES FOR OLDER PEOPLE The Manor House, 37 Stafford Road Walton Stone Staffordshire ST15 0HG Lead Inspector Norma Welsby Key Unannounced Inspection 5 December 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House, Address 37 Stafford Road Walton Stone Staffordshire ST15 0HG 01785 812885 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Richard Charles Britten Mrs Diane Isobel Britten Mrs Phyllis Jean Smith Care Home 33 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (33) of places The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20 February 2006 Brief Description of the Service: The Manor House is located on the periphery of the town of Stone, and is part of the complex known as Waverley Homes. The home is well located to provide good access to a local shop and post office and just a little further to the wide range of facilities available in the market town. It is registered to provide accommodation for thirty-three older people, 6 of whom may have a mental frailty. The home was extended some years ago and provides comfortable and homely accommodation on three floors. Access is facilitated via a shaft lift. The majority of bedrooms are for single occupancy with just two used as shared bedrooms, one of which has an en suite. Within the past year the home has had an area to the back attractively landscaped, including a water feature, raised borders and seating for residents to enjoy. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Ms Norma Welsby carried out an unannounced key inspection on the 5th of December 2006. The Inspection was carried out using the National Minimum Standards. The Inspector was very satisfied with the findings of this inspection which covered many of the standards and just three recommendations were made and no requirements. What the service does well: What has improved since the last inspection? The landscaped garden and surrounding building work has been completed to a high standard and several residents commented positively about the attractive sitting area and waterfall. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents received detailed information about the home to enable an informed choice to be made about the suitability of the home for them. Each resident had a contract with the home and they were assured that the home could meet their assessed needs before moving into the home. No intermediate care took place in the home and therefore, standard 6 was not inspected. EVIDENCE: All residents have been provided with a copy of the Statement of Purpose/Service User Guide. These were seen in residents’ bedrooms and several residents made reference to them. These documents were updated The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 9 following a requirement of the last inspection, (20th February 2006) and were seen during this inspection. All residents also have a contact detailing a statement of the terms and conditions of residency. When a sample of residents were asked, they confirmed their knowledge of the contract and also that they are notified in writing of any changes. The pre-admission assessment of residents is well established at The Manor House, with the Registered Manager taking the lead role. Documentation evidencing the home’s needs assessment and Care Management Assessments were stored in each resident’s personal history file and form the basis of the written plan of care in operation for each resident. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning processes within the home provided staff with sufficient information to meet resident’s needs satisfactorily. Health care needs were met very well and comments received from residents confirmed that they were afforded a high standard of personal care. Medication records and procedures were examined and were satisfactory. Residents were treated with respect and their right to privacy upheld EVIDENCE: Residents care plans were examined and found to provide a range of information about activities of daily living. Each care plan was reviewed monthly and risk assessments were completed and also reviewed monthly. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 11 The daily report was completed and provided an up-to-date picture of the current status of the individual resident. Access to a range of health care professionals was recorded and evidenced that residents’ health care needs were met well. The Inspector briefly met a visiting district nurse who confirmed her satisfaction with the standards provided at The Manor House and it was evident that the home had established a very good rapport with health professional. A Nomad Monitored Dosage System of Medication is used at The Manor House and 8 staff, all of whom have had Safe Handling of Medicines Training, administer medication to residents. The Inspector observed the lunchtime medication being given to residents in the dining room on the ground floor and this was found to be satisfactory. Storage arrangements were satisfactory and quality control measures were also in place. Medication administration records were examined and were satisfactory. There was just one controlled item of medication on the premises and storage/records pertaining to it were also found to be satisfactory. Throughout the period of the inspection the Inspector had extensive discussions with residents, staff and a visitor to the home, along with making many observations. There was much evidence of high standards of care, including the promotion of privacy and respect. Indeed residents and staff spoke about each other with mutual respect. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manor House provides a good range of activities and entertainment in the home. Daily routines are flexible and residents are encouraged to maintain family links. Choice is promoted across many areas of daily life and an high standard of catering is provided. EVIDENCE: Several residents were consulted about their daily routines and all confirmed that varied and flexible arrangements were in place. Many residents enjoy sitting in one of the communal areas, while others prefer the privacy of their own bedroom. While spending time sitting and chatting with residents, the Inspector noticed that the provision of two televisions in the main lounge meant that noise levels were quite high and that for some residents sat betwixt the two, there was sometimes a conflict when the televisions were on different channels. The Inspector discussed this matter with the Registered Manager and made a recommendation that the current arrangements be reviewed. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 13 A varied programme of planned activities is provided at the sister home, Autumn House, which is located on the same cite and on the morning of the inspection a group of residents were visiting Autumn House playing bingo. Later, during lunch, two of these residents chatted openly to the Inspector and advised that they were very pleased to have the opportunity to attend regular activities at the sister home and had made several additional friends there. During this inspection it was noted that there were several posters on display announcing Christmas activities and planned entertainment and several residents who have experienced other Christmases at the home advised that they always have a lovely time, with “lots going on and plenty of good food”. The Inspector was able to have lunch with residents in the main dining room on the ground floor. The home cooked lunch was beautifully cooked and presented and several residents confirmed that the provision of meals was consistently high. In respect of teatime arrangements, there were a couple of comments, received from both residents and a visitor to the home, that it would be preferred if there was a daily choice of a hot light meal or sandwiches. This was recommended to the Registered Manager who agreed to implement this improvement. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure had been issued to residents and was seen on display in the home. Procedures and training were in place for staff to ensure that residents were protected from abuse. EVIDENCE: The complaints procedure is outlined in the home’s Statement of Purpose and Service User Guide. Details were displayed in the home. When asked, several residents confirmed to the Inspector that they would have no hesitation in raising any concerns or complaints that they might have with staff and felt confident that any matter would be appropriately addressed. Several residents were keen to convey to the Inspector that all staff were very “approachable”. The Manor House had not received any complaints in the past year, nor had any been referred direct to the CSCI. Any minor grumbles were dealt with immediately in line with the home’s quality assurance system. Staff are provided with ongoing training in protection and the procedures to follow in the event of abuse being suspected. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 15 Policies and procedures were in place to protect residents from financial abuse. Records pertaining to the management of residents’ personal allowance were examined along with a sample of cash held, both of which were found to be satisfactory. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manor House provides an attractive, comfortable and homely environment, suited to its purpose. Standards of maintenance and hygiene are very high. EVIDENCE: During this unannounced key inspection a tour of the building was undertaken. All communal areas were visited, along with a sample of bathroom/toilets and bedrooms. The home presented as clean, pleasant and hygienic and one resident told the Inspector that there were never any unpleasant odours and that the cleaning standards in the home were “very, very good”. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 17 Several residents confirmed to the Inspector that the home is always “warm and cosy” and it was noted that radiators have been fitted with attractive radiator covers. A random sample of bedrooms were visited and found to be satisfactory and two residents also showed their bedroom to the Inspector and both of these were very comfortable and personalised. It was understood that the home had experienced problems with the shaft lift, but that at the time of the inspection it was in full working order. During the period of it being out of use, a stair lift had been installed but this was due to be removed in line with arrangements made with the Fire Officer. An issue raised in respect of the main lounge has been reported under the group of standards Daily Life and Social Activities and a Recommendation made. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 & 29 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manor House had sufficient staff with the skills mix to meet the needs of residents. On going training provide staff with opportunities to pursue qualifications. Robust recruitment procedures were in place, including POVA First and CRB checks. EVIDENCE: During this Unannounced Key Inspection there were good staffing levels on throughout the day. The Registered Manager was on duty and provided helpful assistance, as did all staff who where consulted during this inspection. Three staff, (namely one senior carer and two care assistants) were interviewed privately and in addition other members of the staff team were also consulted during the inspection. Through these discussions and by extensive observations the Inspector was impressed with the care and commitment demonstrated by all staff. Without exception, all of the residents consulted were also very complimentary about the staff team at The Manor House. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 19 On the day of this unannounced inspection the following staff were on duty: Registered Manager – 8am/5pm Senior Carer - 8am/8pm 2 Carers - 8am/2pm (Bedmaker - 8am/2pm every day) 1 carer - 6am/9am 3 carers - 2pm/8pm 3 waking nights - 8pm/8am plus on call provided by Registered Manager 1 cook - 7am/2pm Kitchen Assistant - 8.30am/2.30pm Kitchen Orderly - 8am/2pm plus 3pm/7pm 1 maintenance 9am/5pm 2 Domestics - 8am/2pm over 5 days plus 1 on Saturday and Sunday Administrative support is provided from Autumn House. The usual care ratios aim to provide four/AM, four/PM and three each night – with the Registered Manager providing additional support. However on the morning of this inspection a carer was poorly and so the manager worked partly with staff, as well as assisting with the inspection. NVQ training is progressing well. Of the 18 care staff 6 have NVQ level 2 or above and 4 more are part way through level 2 and 2 more staff are part way through level 3. Seven care staff hold a current first aid certificate and a wide range of training has been provided during the past year, including courses on Dementia, Management of Continence, Fire Training and Moving and Handling – with more training planned for the new year. Recruitment procedures are well established and are thorough. A sample of staff files were examined and found to be satisfactory. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager was fit to be in charge, responsible and of good character. The ethos and management approach of the home is open and transparent. The health, safety and welfare of residents and staff were upheld and protected. EVIDENCE: The Registered Manager, Mrs Jean Smith had been involved with the home for 22 years and spent the past 15 years as the manager. Mrs Smith confirmed to the Inspector that she had recently completed the Registered Managers Award The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 21 and like her staff team was also pursuing other training opportunities in specific areas of relevance. The Inspector found the Registered Manager to be very experienced in managing her responsibilities to meet the needs of the residents in the home and it was evident that residents and staff benefited from her open, inclusive approach. Without exception all residents and staff who were consulted were very complimentary about the management approach of the home, including the role of the Registered Manager and her senior team. Detailed information had been provided in the pre –inspection questionnaire about maintenance, servicing and associated records. A sample of these, were examined during the inspection including a requirement for Legionella testing. Fire records and risk assessment were also examined and were found to be satisfactory. The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 22 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 X X 3 The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1 Refer to Standard OP12 Good Practice Recommendations Consideration should be given to affording residents with a better arrangement of the televisions in main ground floor lounge to enable everyone to see and hear clearly. Consideration should be given to reviewing the teatime provision to allow residents to choose from a hot meal or sandwiches. Consideration should be given to implementing strategies to reduce staff turnover, as while the core team is very stable, there is quite a high turnover amongst the remainder of the team. 2 3 OP15 OP29 The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Manor House, DS0000005017.V317302.R01.S.doc Version 5.2 Page 25 - 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!