Inspection on 24/05/05 for The Manor House Care Home

This inspection was carried out on 24th May 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 but made no statutory requirements on the home.

Other inspections for this house

The Manor House Care Home 30/04/07

The Manor House Care Home 04/04/06

The Manor House Care Home 17/10/05

The Manor House Care Home 18/11/04

The Manor House Care Home 14/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Manor House Care Home Brook Street Sutton In Ashfield Mansfield Nottinghamshire NG17 1ES Lead Inspector Stephen Benson Announced 24 May 2005 @ 09:30 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 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 C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Manor House Care Home Address Brook Street Sutton In Ashfield Mansfield Nottinghamshire NG17 1ESt 01623 554 552 01623 554 552 N/A Dr Sudaram Rai Dr Thambithurai Raj Chandrani Janice Elaine Bather Care home only (PC) 25 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) Category(ies) of Old age, not falling within any other category registration, with number (OP) 25 Both of places The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service users shall be within category OP Date of last inspection 18/11/04 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 C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first of two unannounced inspections to be carried out between April 2005 and March 2006. The inspection lasted for 6 hours. The main method of inspection used was called case tracking which involved selecting 4 residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. Other residents were spoken with and additional records were seen. A discussion was had with the deputy manager and some of the staff on duty. Three relatives were spoken with and a visiting Community Matron. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Residents said that they would like a bigger choice of activities and for these to happen more regularly. There is not a record kept of residents’ interests to help plan any activities. Residents were positive about the help they get from staff but one resident said that at times they could be more gentle. The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 6 Residents said they knew how to raise a complaint, but only complaints thought to be serious are recorded in the complaints book. A number of chairs in the lounge are too low for residents and are sagging causing residents difficulty when trying to get out. A carpet in one bedroom needs to be replaced. One resident said she would like to have a second chair in her bedroom for when she has visitors. The housekeeper was not aware of the infection control policy. Some staff have been appointed before the necessary checks have been completed and the induction programme for new staff needs to be more detailed. Staff are not getting regular supervision about how they are getting on. Residents have made some comments about the home in a questionnaire, but the points raised have not yet been followed up. 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 C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 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 Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 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 and 4 New residents are assessed prior to admission. EVIDENCE: Care plans seen all showed that an assessment was carried out prior to admission. There has been one recent admission to the home and there was an extended community care assessment on file and the home’s own pre admission assessment, which was carried out before the resident moved to the home. A further assessment was carried out at the time of admission. The resident said that someone came to see her before she moved in and that her daughter came to the home. There is an outstanding requirement set in the previous inspection report to apply for a variation for a resident who was admitted to the home some time ago that was outside of the home’s registration category and before the manager introduced the current assessment arrangements. The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 and 11 The new care plan system is good, but needs to include social needs. There are good arrangements in place for meeting health care needs and residents’ privacy and dignity are respected. EVIDENCE: A new care plan system is being introduced and a number of files have already been changed over. The new system is clear and easy to follow. The plan describes the actions needed to ensure that residents’ health and personal care needs are met, however does not include residents’ social needs. There is a system included to review and update each plan and this had been done on plans seen. There is not any inclusion of residents comments on their care plans, but residents spoken with said that they had discussed their care plan and a quality assurance survey carried out included questions about care plans and some residents had stated that they had seen their care plan. A relative said that she had asked to see her relative’s plan and thought it was good when showed it and staff spoken with said that they had been told to refer to care plans. The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 10 The new care plan includes forms to record all medical appointments and these showed that use is made of a range of services. There are forms to assess oral hygiene, tissue viability, risk of falls and psychological health. There is also a chart to monitor residents’ weight. One resident was being taken to an out patients appointment by a member of staff and an emergency doctors appointment was made for a resident who was feeling poorly. Another resident was taken to the opticians by a relative and the deputy manager spent some time discussing the welfare of a resident who is currently in hospital with a relative. A Community Matron who was visiting a resident was spoken with and said that she had asked staff to monitor the resident and this had been done. She also said that staff were helpful and interested in the residents well being. One resident who was case tracked had specialist equipment for the prevention of pressure sores and staff spoken with knew the indicators to watch for. Residents said that staff will always call a doctor for them if they ask them to and a relative described discussing her relative’s health with staff. The lunchtime medication round was observed and this was correctly managed. All Medicine Administration Records were fully completed and residents were asked if they had any pain and needed a painkiller. Some residents have been assessed as being able to administer their own inhalers. Staff spoken with described good practices in promoting residents privacy and dignity and said this had been included in their induction and had been given written information about this. Residents said that they get the help they need from staff and one resident said that staff are so good they are almost too accommodating. Another said that staff were very helpful but sometimes could be more gentle when lowering onto the toilet. There is a section in care plans, which details residents’ wishes following death, and there is a checklist for staff to follow to ensure that appropriate respect is given. The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 11 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 and 15 Residents should be given more opportunities to take part in activities and to make choices. Contact with family and friends is encouraged and mealtimes are well managed. EVIDENCE: During the inspection residents were listening to music and watching television. Some residents had their nails attended to by staff. The home does not have an activities programme and any activity provided is left to the instigation of staff. A number of residents commented on the quality assurance survey carried out that they would like more and varied activities. The deputy manager agreed that this is an area that needs to be improved. A relative said that she would like to see a list of activities displayed so she knew what was going on. Staff spoken with were not aware of individual interests of residents. There was a spring fair held the previous week, which had been opened by the local Member of Parliament who is a prominent government minister. One resident said that this had given them something to talk about. There were a number of visitors to the home during the inspection who sat with their relatives both in the lounge and their room. Some visitors were seen discussed care issue with staff and exchanging information. Visitors commented that they are always made welcome when they come and a resident said that she looks forward to her daughter visiting. The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 12 Staff were seen offering choices to residents, asking if they wanted their nails doing and whether they wanted a painkiller. Staff also went round to each resident asking them to choose which lunch option they wanted and this started discussions between residents. A male carer said that he always asked female residents if they were happy with him assisting them or whether they wanted a female. There were some opportunities for choice to be made available to residents that were not used, for example offering a choice of drink with lunch. The kitchen was well organised and clean. There is a rolling menu, but the cook said that this is not rigidly stuck to as residents often request other dishes. A record is made of all food provided. There were well stocked food stores and included fresh fruit and vegetables. Residents said that they are well fed and relatives said that the food is always very good. The dining room was well furnished and there were flowers on each table. Lunch was well presented. The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 13 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 and 18 Complaints are responded to appropriately but only ones considered serious are recorded. There are policies and procedures in place to protect residents from abuse. EVIDENCE: There is a complaints procedure in place and a book to record any complaints in. This is used to record matters of serious concern. There is one recent entry concerning how a member of staff assisted a resident. This is being thoroughly dealt with, but there is nowhere to record minor complaints. Residents said that if they have any concerns they tell the manager who sorts things out. A relative said that you can raise anything, everyone is very approachable. There are policies on the protection of vulnerable adults and whistle blowing in situ in addition to the Adult Protection procedures. Applications have been submitted for the managers to attend adult protection training. Residents and relatives said they had not seen anyone being mistreated. The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 14 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) 19, 24 and 26 The home is well maintained, warm and comfortable. Rooms were all well decorated and furnished with the exception of some chairs in the lounge which need replacing and a carpet in a bedroom. The home is clean and fresh throughout and the laundry operates well. EVIDENCE: The home is well decorated with many homely touches. Some of the chairs in the lounge are sagging and too low, making it difficult for residents to get in and out of them. There is a maintenance book to record any repairs in and a handyman is employed to carry out routine maintenance. Staff said that they felt that the layout of the building was good and residents described the home as lovely. Bedrooms seen were all well personalised. One resident said that she would like another chair in her room so her daughter can sit down when she visits. There is an outstanding requirement set in the previous inspection report to 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. This room is not in The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 15 use at present. This requirement is repeated in this report and must be complied with to avoid possible enforcement action. The home was clean throughout and smelt fresh and cleaners were on duty during the inspection. A relative said that this is how the home always is and also said that the laundry is very good. Residents said that the home is always kept nice and clean. There is protective clothing available and there is a sluice. The housekeeper was not aware of the home’s policy on infection control. The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 16 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) 27, 29 and 30 Thee are sufficient staff on duty to met residents’ needs and they receive the required training. Not following the correct recruitment practices means that staff are working in the home without the required checks being carried out, placing residents at risk. EVIDENCE: The rota shows that there is always a minimum of three care staff on duty during the day and staff spoken with said that this was always the case. There are usually four staff on during the mornings as there is more to do. There is also cooking, domestic and maintenance staff on duty. There are two awake staff on duty over night. Residents and relatives said that they were happy with the number of staff on duty. A sample of staff files were seen and these showed that the correct recruitment practices had not been followed with regard obtaining Criminal Records Bureau checks and references. Staff are given a copy of the code of conduct and practice set by the General Social Care Council. Training is well organised and mandatory training is provided. Staff said that the manager is right on top of training and urges staff to attend courses. Residents said that staff seem to know what they are doing. The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 17 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) 31, 32, 33, 35 and 36 The manager is respected by staff and residents and is competent at her job. There is openness in the home and the views of others are respected. Views of staff and residents have been obtained through a survey but issues raised have not been followed up. Staff induction is not recorded. EVIDENCE: The manager previously managed the home for a number of years and has returned to the post. The manager is currently working towards National Vocational Qualification level 4 and expects to complete this in June 2005. Residents said that the manager gets things done and staff said that she is very professional and handles people diplomatically. Staff said that they are able to put their views forward and these are taken on board. There are staff and residents meetings held and these were described as good as everyone can have a say. The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 18 Both staff and residents have been asked to complete a quality assurance questionnaire. There were some issues raised by residents in these that have not yet been followed up. There is a system to manage personal allowances for residents where required. Details records are kept of what the money is spent on, receipts are obtained and two staff sign each transaction. There is an outstanding requirement set in the previous inspection report to develop a detailed induction for new staff and provide staff with formal supervision. A new member of staff described a more detailed induction than was shown by the induction record. The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 19 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 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 x x x x 2 x 2 STAFFING Standard No Score 27 3 28 x 29 2 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 3 3 2 x 3 2 x x The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. 7. 8. Standard 4 7 10 12 14 16 19 24 Regulation 12 15 12 16 12 22 23 16 Requirement Apply for a variation for out of category resident Include residents social needs in care plans and their comments on the plans Detail the assistance each resident wishes in the care plan Provide more frequent and varied activites 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 Enusre that all staff are aware of the policy on infection control Correct recruitment practices must be adhered to Follow up issues raised in the quality assuraance questionaire Develop a detailed induction for new staff C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Timescale for action Immediate 1st August 2005 1st June 2005 1st August 2005 1st August 2005 1st June 2005 1st August 2005 1st July 2005 9. 10. 11. 12. 13. 24 26 29 33 36 16 13 19 24 18 1st June 2005 1st July 2005 1st June 2005 1st July 2005 Immediate Page 21 The Manor House Care Home Version 1.30 14. 36 18 Provide staff with formal supervision Immediate 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 12 Good Practice Recommendations Produce and display an activities programme The Manor House Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 © 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 Care Home C53 C03 S8716 The Manor House V229331 240505 Stage 4.doc Version 1.30 Page 23 - 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. 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