Inspection on 06/07/05 for The Manor House

This inspection was carried out on 6th July 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 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 30/11/05

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 DN15 9JG Lead Inspector Janet Lamb Unannounced 6 and 25 July 2005 9:30 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 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 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 LD Learning Disabiity (12) registration, with number of places The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can only accept the two named specified service users over the age of 65 years. Date of last inspection 25/10/04 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. communal areas are large and spaceous. 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. The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over eight hours, on two visits, and was one of the two inspections the home is required to have in each year. The Inspector looked around the house and talked to service users, the Manager and staff. Some of the records were inspected. Of the 12 service users living in the home four were spoken to. The Inspector had lunch with four service users and two staff on the first visit. There were two care staff working in the home on each visit, and the Manager was present for most of the inspection, but had prior engagements to attend to on both days. Two care staff were interviewed. The Inspector observed interaction between service users and staff, and between service users. What the service does well: What has improved since the last inspection? The service has begun to improve the physical environment. Work has just begun on an upgrading of facilities. Staff are now doing the Learning Disability Award Framework programme and some are doing NVQ level 2 and/or 3. New staff do not begin in post until a Criminal Records Bureau check has been completed. The service has increased and improved the staffing numbers in the building at night as a result of a fire in June. The Manager has begun the NVQ level 4 Registered Manager’s Award. The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 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 Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 8 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 standard(s) 2 only. The Manager and staff do a good job of finding out service users’ individual needs, having worked with many of them for a number of years. The staff team continue to do a good job because of well-established relationships. EVIDENCE: There are copies on files of service users’ placing authority community care assessment documents and care plans. There are also Prime Life Ltd assessment documents in files. Information from these documents and observation of and discussion with service users is used to discover needs in greater detail. Of the service users spoken to it was clear they have very different needs, but they said they speak to the Manager anytime about individual needs. Many service users have lived in the home for up to 20 years and have established a settled lifestyle, where routine is important to them. They were observed making choices according to their preferences. There are some long-standing relationships between service users and staff and between service users, and the general impression given is that almost everyone knows each other’s aspirations. The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 9 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 standard(s) 6, 7 and 9. The Manager and staff do a good job of informing service users about plans of care and diary notes etc. enabling service users to make their own informed choices and decisions. The staff team do a good job of supporting service users to take risks to maintain independence. EVIDENCE: There are individual plans of care in place covering the areas in standard 2 identified as requiring assessment. Service users have access to their files and plans of care, and have signed them in confirmation. Diary notes show decisions made by service users, with support where necessary. There are risk assessment documents in place to show service users can take risks in their efforts to be independent, but safely and with support. Staff offered help and guidance and discussed options and choices with service users. Service users spoke of their preferences and wishes and acknowledged their written plans of care. As the progressed they gradually bathed and dresses in private, and were observed to take late breakfast, went to the local shops or sat in the garden, and some prepared their own lunch. Service users [pleased themselves and were in no hurry in following their own routines. The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 10 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 standard(s) 15, 16 and 17. The Manager and staff do a good job of encouraging service users to have contact with family and friends and to protect themselves in relationships. The staff team does a good job of respecting service users’ rights and encouraging them to take responsibility. Food provided in the home is healthy and balanced, but reflects service users’ choices and preferences. EVIDENCE: Service users spoken to explained their continuing family connections. One spoke about his luck with girlfriends. From the conversations with service users and staff, it is clear that most service users have contact with family via visits, letters and cards, and telephone calls. One or two service users spend weekends with parents or take holidays with them. There are a small number who have no family connections, only friends in the home or in other homes and day care services. Service users are provided with sexual health information and support as necessary. Most service users have a key to their room and all have free access to communal areas. Staff were observed to be discreet in supporting them with personal care. Their attitude and the information supplied in interview implied service users privacy and dignity are respected, and choices are encouraged. Diary notes and records showed The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 11 service users have contact with important people in their lives, and their rights are respected. Service users spoke with satisfaction about food they receive, of their choice and at times they prefer. Some assisted to prepare and cook their own meal at lunchtime. Menus are followed for the evening meal, but individual choice is respected at breakfast and lunchtimes. The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 12 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 standard(s) 18 and 19. The Manager and staff do a good job of providing service users with support and care of their own preference. The physical, emotional and health needs of service users are well met. EVIDENCE: Service users spoken to explained they are able to make their own choices and decisions about rising, going to bed, when and where to go, who to spend time with etc. It was easier for some to make their choices known verbally, but others demonstrated this with their actions. Staff and the Manager confirmed the levels of support provided and demonstrated a commitment to encouraging choice, privacy and independence. There are few technical aids and little equipment needed by service users at The Manor House, but persona, social and health care and support is provided according to assessed needs. This is recorded in plans of care, in diary notes, and progress/care charts, as well as in GP visit and health care intervention records. The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 13 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 standard(s) 22 and 23. Service users are listened to on a daily basis and their requests or comments are satisfactorily acted upon. Service users are well-protected form abuse, neglect and self-harm. EVIDENCE: There is a newly revised complaint procedure in place that is also in picture format, which service users did not relate to, but were clear about whom to consult if they had a complaint to make. The Manager explained those able to use the picture format and are made aware of it as necessary. Records of complaints are kept and show any action taken and whether or not the complainant is satisfied with the outcome. There have been no complaints since the last inspection. Observation of interaction between service users and staff showed requests are made verbally by service users, and staff act upon these appropriately. Service users are protected in the home by a Manager with Protection of Vulnerable Adults training, and staff that are made aware of the policies and procedures in place, which reflect the ‘No Secrets’ initiatives. Staff have enrolled for the Learning Disability Award Framework programme and are also doing NVQ level 2 and 3, all of which cover adult abuse training. Staff training undertaken is recorded in their individual files. Service users spoken to were confident they could talk to one of the staff or the Manager about any problems or worries they may have, or to make any disclosures of abuses or unfair treatment or practice. The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 14 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 standard(s) 24 and 30. Service users live in a clean and comfortable home that is suitable for its stated purpose. Furnishings, fittings and equipment are of a satisfactory standard and quality. EVIDENCE: A tour of the premises and discussion with service users and staff revealed the home is currently in the early stages of a refurbishment programme and upgrading of facilities. There had been a fire in the quiet lounge on the night of 30th June 2005. A visit by the CSCI was made to the home on the 1st |July to assess the situation. The local fire service department has requested work to upgrade the fire safety system and to meet requirements left after the fire, to improve procedures in an emergency and to ensure the safety of service users, especially at night, by increasing staffing presence in the home to one waking staff and one sleeping staff member. A staff sleep room has been created from a storage area. Work was also required to clean up, decorate and refurnish the quiet lounge. This was done within 48 hours of the fire occurring. Generally the house is in need of upgrading and refurbishment, and it is expected the environment will be improved with the completion of the work, which is still in its early stages. The house is clean and comfortable and service users enjoy a homely environment. The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 only. Service users’ needs are well met by staff that are quite well trained, but there is room for improvement in this area. EVIDENCE: Since the last inspection staff have signed up for and have been completing the Learning Disability Award Framework programme. Some staff are also working on NVQ level 2/3 in Care, but the home does not yet have 50 of care staff with the award. Prime Life Ltd holds information on training done by all staff, and devises the training and development programme for each home in the company each year. The company informs Managers regarding training updates and refresher courses needed. The training and development plan for The Manor House is devised at headquarters and sent to the home to be implemented by the Manager. The home meets the requirement to provide each staff member at least five paid days training per year, through this system of working. Staff interviewed were clear about the courses they had done and intend to do. No one spoken to has undertaken training in relation to religious or cultural needs of service users. Cleaners are not employed in the home, but care staff and service users undertake cleaning chores. The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No judgements were made in this section. EVIDENCE: No evidence was obtained in this section. The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 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 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Manor House Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 18 Are there any outstanding requirements from the last inspection? Yes, but this is because some have not been checked. 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. Timescale for action 31/10/05 2. 3. 4. 5. 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. 2. Refer to Standard YA32 YA37 Good Practice Recommendations The registered provide should ensure 50 of care staff achieves NVQ level 2 by the end of 2005. The registered manager should complete NVQ level 4 Managers Award by the end of 2005. The Manor House J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 19 Commission for Social Care Inspection 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 J54_s2816_The Manor House_v229650_230605_Stage 4 .doc Version 1.30 Page 20 - 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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