Inspection on 08/09/05 for The Manor House

This inspection was carried out on 8th September 2005.

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

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

Other inspections for this house

The Manor House 20/04/09

The Manor House 02/05/07

The Manor House 29/11/05

The Manor House 15/03/05

The Manor House 20/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE THE MANOR HOUSE North Walsham Wood North Walsham Norfolk NR28 0LU Lead Inspector Jenny Rose Unannounced 08 September 2005 10:00 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 I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Manor House Address North Walsham Wood, North Walsham, Norfolk, NR28 0LU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01692 402252 01692 402252 The Manor House (North Walsham Wood) Limited Mrs Pamela Mary Davis Care Home 52 Category(ies) of DE(E) Dementia - over 65 (10), OP old age (42) registration, with number of places THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15 March 2005 Brief Description of the Service: The Manor House is a care home providing personal care for up to 52 older people. The home is owned by the Manor House (North Walsham Wood) Limited.The home is located close to the market town of North Walsham, with all the usual amenities, and is set in 18 acres of gardens and woodland, all of which are accessible to service users. There are also bird aviaries within the grounds. The home provides accommodation in 45 single bedrooms, 2 of which on the day of the inspection were being used as short stay accommodation and 3 shared bedrooms ofwhich, on the day of the inspection, 2 were being used by 2 married couples. Most of the bedrooms have en-suite facilities. Service user accommodation is located on the ground and first floors.There is extensive communal space in the home including a conservatory, dining room, lounge, lounge/diner and library. Assisted bathing facilities are also situated throughout the home and assisted passage between floors is via a shaft lift.The home has extensive, well-maintained grounds and there is ample parking available. This home has won awards for its pet-friendly approach and this is well monitored THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, taking place over 6 hours on a weekday. A partial tour of the building was undertaken. The Manager, Ms Pamela Davis, was on holiday and Ms Ann Gibbs, a senior member of staff, was in attendance throughout the inspection. There were 50 service users in the home on the day, including one person visiting for day care and one person receiving short-term care. Many records were seen, 4 members of staff were spoken to, 4 visitors, two groups of service users, 10 in all, another group of 2 service users and 2 service users privately. What the service does well: What has improved since the last inspection? What they could do better: * It is recommended that there be a set pre-assessment procedure to form the basis of the care plans. * It is recommended that individual staff files should contain photographs. * It is recommended that in the process of revising the care plans, these should be in individual folders to maintain confidentiality. * Care plans should also contain more comprehensive life histories, and activities recorded, where this is possible and appropriate. * It is recommended that there should be a Comments Box for any comments THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 6 to be made, other than the annual, formal satisfaction survey. * There should be regular formal staff supervision, a record of which should be signed by the member of staff and the supervisor. 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 I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 There had been comprehensive information gathered regarding the most recent service user, but a set format for the home’s pre-assessment procedure, forming the basis of the care plans, would further ensure that the home could meet the service user’s needs. EVIDENCE: There had been a recent admission of a service user and the information for his care was contained in information from Social Services and from the hospital, which was very detailed. Mrs Gibbs confirmed that the GP surgery was always helpful in supplying the necessary background medical information to the service user to share with the home. Relatives often visited to look round the home on behalf of prospective service users and frequently prospective service users would visit themselves. On the day, this was in fact occurring. There would be a trial period of stay with a review before this became permanent. THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 9 It was evident that there had been good liaison between the hospital and the home, as this most recently arrived service user had been supplied with specialist equipment from the hospital to meet his needs. However, there did not appear to be a set format for carrying out a needs assessment for prospective service users without an existing care plan, in order to ascertain that the home could meet these needs. There is therefore a recommendation that a suitable set format be found and adopted for this purpose. THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.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) 7,8,9,10 There are good care plans, but in the present reorganisation, there are minor improvements which could be made to ensure that the home further meets the needs of the service users. EVIDENCE: There were good care plans with photographs, medical history, personal preferences and risk assessments. There was evidence that other Healthcare professionals’ advice was sought if necessary and Mrs Gibbs confirmed that there were good relationships with the Community Nurses. One service user spoken to confirmed that she felt well attended with the GP and that her medical problems received good attention. The care plans seen were reviewed on a monthly basis with the service user and/or their relative, who signed the review, if appropriate. There was evidence of risk assessments from a care plan of a service user with partial sight, who chose to walk up and downstairs. This was risk assessed and reviewed regularly in conjunction with the service user and it was noted that the family were aware. THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 11 Individual preferences were recorded, including the service user’s wish for a telephone in their room. One service user’s care plan seen included the care plan for her dog, which lived in the home, with reminders for veterinary appointments, which is seen to be good practice. The home is in the process of reorganising the safe keeping of the care plans by creating an office on the first floor, where the plans for service users on that floor will be kept. Similarly, an office will be refurbished on the ground floor for the same purpose, which will be beneficial to staff. As the organisation of the care plans are in the process of being reviewed, there are recommendations in this report for further improvement. It is recommended that all care plans should be filed individually, rather than in a communal file, to ensure better attention to confidentiality when other professionals need to view such details. In addition, there should be more information, should the service user wish, for a more comprehensive life history; the recording of service users’ aspirations and activities, in which they wish to engage and the wishes of service users for their funeral arrangements, or a note of from whom to obtain such information, should be recorded, if appropriate. On this occasion, the medication round was not observed and not all the elements of the Standard inspected, but a risk assessment for a service user administering her own medication was seen and there were lockable facilities seen in one bedroom for the storing of medication. There was also evidence that staff receive training in the administration of medication. Therefore, those elements of the Standard inspected were met. It was observed and confirmed by the service users spoken to that the service users felt staff respected their privacy and dignity on all occasions. THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.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) 12,13,14,15 The home works hard to match service users’ interests, to support the maintenance of contact with family and friends, and in giving service users choice and control over their lives, as far as possible. EVIDENCE: There is an Amenity Committee which exists to raise money for entertainment and outings for service users. For example, there had been trips on a boat and a visit to the End of the Pier Show. Every other year there is a summer fete. This year there is a Christmas Fair planned. The Amenity Committee also arrange for a clothing company to visit the home and there were notices of a forthcoming Bodyshop Evening with Aromatherapy. A group of service users were seen to be celebrating the birthday of one of the service users in the conservatory area and all the service users were offered an alcoholic drink, if they wished. The home positively encourages the service users to bring their pets, if they wish and budgerigars, several dogs and cats were seen in the home, as well as the dogs who accompanied members of staff to work. This is well monitored. During the inspection there was a representative visiting individual service users from the Catholic Church. There was also a visiting member of the Church of England for a Prayer Meeting which is held on a regular basis, and THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 13 until recently was organised by one of the service users. There is also a representative of the Methodist Church who visits regularly. One visitor, who visits two or three times a week, and two other relatives who visited on a regular basis were also spoken to. One visitor voiced the opinion that the care her relative received in the home was good. She said that her mother chose to eat her meals in her room and did not always wish to have the meals which were planned, but these preferences were accommodated as far as possible. One service user spoken to said that she chose to attend to her own personal needs without staff assistance in the mornings, but that staff would always help if she wanted it. She remarked that she felt safe in the home. During the afternoon of the inspection, several service users were choosing to stay in their rooms watching Cricket on the television. Several service users and visitors remarked that the food was good and that there was choice. The meal was seen to be appetising, nutritious and well presented. The service users have the option of taking their meals in three dining rooms all of which are pleasant areas, which, in the words of one member of staff are also “tastefully decorated”, or in their rooms. Those service users needing help with feeding were in one dining room, attended by members of staff. THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.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, 18 There is a complaints policy and procedure in place, but the Complaints Book was not available on the day. There is a policy and procedure in place for the Protection of Vulnerable Adults and staff confirmed their knowledge of these issues, which should ensure the protection of service users as far as possible. EVIDENCE: One visitor to the home said she was aware of the complaints procedure and would know how to voice any concerns. However, several visitors felt that the availability of Comments Box for any issues concerned with the home, would be beneficial. There is therefore a recommendation for this. In the absence of the Manager, it was not possible to view the Complaints Book, although there is a policy and procedure for this. This should be revisited at the next Inspection. One service user spoken to said “They listen here. I had cause for concern over a routine and they put things right for me”. Another service user also confirmed that should she have a complaint she would know how to do this. All the staff spoken to were aware of the issues surrounding the Protection of Vulnerable Adults and felt able to put into practice the Whistle Blowing Policy of the home, should it be needed. THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.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) 20, 23,24,26 The grounds and the buildings of the home provide a comfortable, well maintained environment, which is full of interest for service users. EVIDENCE: The home is situated in extensive, wooded grounds and an attractive, well maintained, lawned area with hedges, which provide a pleasant environment in which service users can walk or sit. There are squirrels, deer, birds and other wildlife, which provide interest for service users. The buildings of the home have several architectural features and the entrance hall is welcoming and interesting with a fish tank and fresh flowers for decoration. One visitor remarked that: “the environment of the home improves the quality of life of the residents”. Facilities have been improved within the home regarding two bedrooms, one containing wheelchair access into a courtyard area. The home is in the process of creating a new office area on the first floor and a refurbished one on the ground floor. This will improve the convenience of the working environment THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 16 for the staff and provide better organisation and confidentiality for care plans, which is dealt with elsewhere in this report. There were three Dining Rooms and service users could choose where they wished to sit and several communal areas which are well decorated and in keeping with the style of the house. “It is very pleasant here”, remarked one service user. The bedrooms of service users, which were seen, were comfortable and if wished, furnished with the service users’ own furniture and possessions. One service user was pleased to be using her own bedlinen. Many rooms had access outside, through French doors, should the service user wish to use them. Two visitors to the home commented separately on the cleanliness of the home. All areas of the home were seen to be clean and hygienic. THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.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) 29,30 Recruitment practices for the home are good, but would be further improved by the inclusion of all the documentation required. The enthusiastic staff feel they are a good team and that there is good communication with management, but this would be further improved by regular, recorded supervision of staff. EVIDENCE: The recruitment practices in the home were examined. Application forms were seen, which sought the appropriate information, particularly in regard to any gaps in employment, and the secretary confirmed that two references were always sought. There were no photographs of staff on their files, but the secretary also confirmed that Drivers Licences were required, or passports, from which photocopies were taken as ID. CRBs were seen, but the one for the most recent member of staff had been transferred from another home in the vicinity. Whilst she was not involved in the personal care of service users, a new CRB is required. It is also recommended that individual staff files should include photographs, since, in all, there are 62 members of staff. One new member of staff spoken to confirmed that she was on a three months’ probationary period, but she was enjoying working in the home and having sufficient time to talk to the service users. One regular visitor to the home remarked “the staff are not rushed…” and a another that “the girls are very friendly”, and this was confirmed by several of the service users spoken to. THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 18 A senior member of staff spoken to confirmed that new members of staff would work alongside more experienced staff members, and would be supernumerary, during their initial training. The members of staff spoken to all confirmed that they felt they worked as a good staff team. They were enthusiastic about their work, which one member commented on as being “rewarding”. They reported that there were good handovers at the end of shifts, good communication with senior staff and the Manager. They also felt that the level of care they delivered was high. The senior carers can call a staff meeting if they wish and there are yearly staff appraisals, which were seen to be comprehensive, together with a statement of aspirations signed by the member of staff. One member of staff spoken to had been risk assessed for her pregnancy and was very satisfied with the way the home had accommodated a balance between her family commitments and the hours she worked. There was evidence from the members of staff spoken to and the training and development plans that there were good training opportunities for staff, but in the Manager’s absence there were no percentages available for the number of staff who had NVQ qualifications. All care staff received induction training and had the opportunity to take part in courses, such as Dementia Awareness, Parkinsons Although all members of staff spoken to confirmed that communication was good, there did not appear to be any regular, recorded supervision and there is therefore a recommendation for this. THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 19 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) 33,38 The home conducts a regular service user survey, but the availability of a comments box would further ensure that the home is run in the best interests of service users. There is evidence of good maintenance in the house and gardens, but in the absence of the Manager records were not available to examine all the elements of the Standard. EVIDENCE: There had been a recent service user survey, a copy of which was seen, which attempted to elucidate the views of service users’ views on such issues as the atmosphere of the home, the décor and cleanliness, care and health issues, as well as meals, activities and any concerns or complaints. As this questionnaire was named, as commented on elsewhere in this report, it is recommended that there be a Comments Box available for anyone who wished to make an unnamed comment. THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 20 The gardens and the decoration in the house are well maintained. The home employs a full-time and a part time maintenance person, both in the gardens and the house. However, in the absence of the Manager the relevant records for other safety issues within the home were not available. THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 21 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 x x 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 x 3 x x 3 3 x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x 3 x x x x 3 THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 22 N/A 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. 3. 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. 2. Refer to Standard OP3 OP7 Good Practice Recommendations It is recommended that consideration be given to the adoption of a set format for a needs assessment where one does not accompany the new service user. It is recommended that in reorganising the care plans they should include more detailed life histories, activities, wishes for funeral arrangements where appropriate and filed individually. It is recommended that staff files should include photographs of individual members of staff It is recommended that there be a Comments Box available in addition to the annual service users satisfaction survey, in order to ensure continuous self monitoring of the service. It is recommended that formal structured 1:1 supervision sessions are adopted. 3. 4. OP29 OP33 5. 0P36 THE MANOR HOUSE I55 S27287 The Manor House V248144 080905 Stage 4amended.doc Version 1.40 Page 23 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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