This inspection was carried out on 17th October 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.
CARE HOMES FOR OLDER PEOPLE
The Manor House Care Home The Manor House Brook Street Sutton In Ashfield Mansfield Nottinghamshire NG17 1ES Lead Inspector
Stephen Benson Unannounced Inspection 17th October 2005 10:00 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 Care Home DS0000008716.V259343.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 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 Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Manor House Care Home Address The Manor House Brook Street Sutton In Ashfield Mansfield Nottinghamshire NG17 1ES 01623 554552 01623 554552 starryeyed1@ntlworld.com 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) Dr Sudaram Rai Dr Thambithurai Raj Chandran Janice Elaine Bather Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users shall be within category OP Date of last inspection 24th May 2005 Brief Description of the Service: The Manor House provides support for up to 25 people falling within the category of old age only, service users outside of this category may not be accepted without an application for and approval of variation of registration. The home is situated close to the centre of Sutton in Ashfield with good access to shops, local facilities and transport. All of the bedrooms are single some are en suite. There are gardens to the front of the property and a small car park to the rear. The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections carried out between April 2005 and March 2006. The inspection lasted for 3 ½ hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, care staff on duty and care practices were observed. No relatives were spoken with but a visiting district nurse was. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. The inspection focussed on key standards not inspected at the last visit and the requirements that were set. What the service does well: What has improved since the last inspection? What they could do better:
There are 8 outstanding requirements from the last inspection which the reason for was explained as being either due to lack of time following the departure of the deputy manager who has not been replaced or because money has not been made available. The outstanding requirements are
The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 6 repeated in this report and if they are not complied with within the timescales set the Commission for Social Care Inspection will consider taking enforcement action against the providers. There should be a record kept in residents care plans of their social needs and residents should have opportunities to comment on their plans. Residents said that they had not seen their plans. There should be a record made of ways that staff can increase residents’ opportunities to make choices. Residents said they knew how to raise a complaint, but only complaints thought to be serious are recorded in the complaints book and a record should be made of all complaints made. A number of chairs in the lounge are too low for residents and are sagging causing residents difficulty when trying to get out and these need to be replaced. A carpet in one bedroom needs to be replaced. One resident repeated from what she said at the last inspection that she would like to have a second chair in her bedroom for when she has visitors There must be a training programme in place to ensure that staff receive the required training on safe working practices. A number of staff did not have the required training. Ways of providing the manager with additional management support are needed which could be done through appointing a new deputy manager or an administrator. There needs to be a detailed induction programme for new staff and staff should have regular supervision to discuss their work. Temperature tests are carried out on the hot water storage system, but the temperature of the hot water tank needs to be increased to over 60 degrees centigrade. 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 Care Home DS0000008716.V259343.R01.S.doc Version 5.0 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 Care Home DS0000008716.V259343.R01.S.doc Version 5.0 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 the following standard(s): None EVIDENCE: The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 7 and 10 The home does not know the social needs of residents. EVIDENCE: Requirements were set at the last inspection to include residents’ social needs in care plans and to record their comments on the plans and to detail the assistance each resident’s wishes. The manager said that she has not had the time to include social needs due to the departure of the deputy manager. There were no records showing residents comments about their plans and residents said they did not know about their plans. There was clear detail as to the assistance residents need seen in care plans sampled. The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 12 and 14 More time is needed to ensure that residents’ social needs are addressed and that they have the opportunities to exercise choice and control over their lives. EVIDENCE: Requirements were set at the last inspection to provide more frequent and varied activities and to include ways of increasing opportunities for residents to exercise choice in care plans. The manager showed a newsletter for September, which listed the activities on offer for that month but said that she has not had the time to produce a similar one for this month. The programme included weekly Tai Chi sessions which residents said does them good. There has been an increase in the amount of activities on offer and staff said they provide activities in the afternoons. The manager said that she has not had time to include ways of increasing choice for residents in care plans. The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 16 The complaints procedure is not designed to deal with minor complaints. EVIDENCE: A requirement was set at the last inspection to make a record of all complaints received as the system in place is designed to address serious matters. No change has been made to the system and the position remains the same that only serious matters are dealt with through the homes complaints procedure. Residents said that staff are very good and deal with things they tell them. The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 19, 24 and 26 The home has been slow to respond to identified improvements needed. EVIDENCE: Requirements were set at the last inspection to replace sagging and low chairs in the lounge, provide a new carpet in a bedroom and to provide a second chair in a resident’s bedroom. None of these requirement s have been complied with. The manager said that she does not have access to budgets for this type of expenditure. The provider was spoken with on the telephone who gave his agreement for the purchases to be made. The resident who had asked for a second chair in her bedroom said that she still wanted one for visitors to use. The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 The management of the home is suffering as a result of not replacing the deputy manager. Staff are not receiving the training they require to carry out their duties safely. EVIDENCE: The deputy manager has left the home since the last inspection and has not been replaced. This has left the manager responsible for all administrative and management duties A requirement was set at the last inspection to ensure that the correct recruitment practices are followed. There have not been any new staff appointed since the last inspection but the manager said she was aware that staff cannot start prior to obtaining a Criminal Records Bureau check and obtaining satisfactory references. There were no up to date staff training records and there are a number of staff who have not received the required mandatory training on safe working practices. The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 Residents’ views have influenced the running of the home. Staff are not receiving the support through supervision and training to do their job to the best of their ability. EVIDENCE: The manager is working towards the NVQ level 4 qualification and has the required experience for the position. A requirement was set to follow up issues raised in a quality assurance survey. The manager has audited the questionnaires and prepared an action plan covering issues highlighted. There were requirements set to develop an induction programme and to provide staff with formal supervision. These have not been addressed and the manager explained that these also had not been done due to time pressures. The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 15 Water temperatures are being checked weekly, however the recorded temperature for the storage of hot water is recoded at 52 and 53 degrees centigrade rather than at 60 degrees centigrade to prevent risk of Legionella. All fire safety checks and tests are being carried out at the correct frequency. The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 16 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 1 15 X COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 x 1 x X X X 1 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 1 X 2 The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? YES 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 4 5 Standard OP7 OP14 OP16 OP19 OP24 Regulation 15 12 22 23 16 Requirement Include residents social needs in care plans and their comments on the plans Include ways of increasing opportunities for residents to exercise choice in care plans Make a record of all complaints received Replace sagging and low chairs in the lounge Provide a new carpet in room 21 and required furnishings unless there is good reason not to in which case record this in the care plan Provide a second chair in residents bedroom Ensure al staff have up to date training on safe working practices Develop a detailed induction for new staff Provide staff with formal supervision Ensure the hot water is stored at a temperature above 60 degrees centigrade Timescale for action 01/01/06 01/01/06 01/12/05 01/12/05 01/12/05 6 7 8 9 10 OP24 OP30 OP36 OP36 OP38 16 18 18 18 13 01/11/05 01/03/06 01/02/06 01/01/06 01/11/06 The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 18 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 27 Good Practice Recommendations Recruit a new deputy manager or administrator The Manor House Care Home DS0000008716.V259343.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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