Inspection on 04/03/06 for The Manor House, Frenchay

This inspection was carried out on 4th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Manor House, Frenchay 18/03/08

The Manor House, Frenchay 14/11/06

The Manor House, Frenchay 25/07/05

The Manor House, Frenchay 10/02/05

The Manor House, Frenchay 29/09/04

The Manor House, Frenchay 24/03/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 The Manor House Beckspool Road Frenchay South Glos BS16 1NT Lead Inspector Melanie Edwards Unannounced Inspection 4 March 2006 09:30 The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 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 DS0000003354.V273661.R01.S.doc Version 5.1 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 Adults 18-65. 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 DS0000003354.V273661.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Manor House Address Beckspool Road Frenchay South Glos BS16 1NT 0117 9566424 0117 9566050 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) Mrs Marilyn Joan Clarke Ms Susan Dorothy Williams Care Home 32 Category(ies) of Learning disability (32), Physical disability (32) registration, with number of places The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 32 persons aged 18 - 64 years May accommodate up to four persons under 18 years of age Date of last inspection 25th July 2005 Brief Description of the Service: The Manor House is situated in a semi-rural location in Frenchay Village within close proximity to the M4 and Avon Ring Road. There are shops and facilities within a mile of the home.The home is registered to provide residential care and accommodation to 32 adults with a learning and physical disability. Presently the home has 25 residents. The Manor House is a large detached property that is divided into two units Chestnut and Arandel each with its own facilities including two lounges, a dining room and kitchenette. Accomodation is on three floors. There is a lift which is accessible to wheelchairs to the first floor only. Over the last few years the home has been ‘down sized’ to provide more single rooms with some having ensuite facilities. Several of the rooms have been modernised. The home provides some ground floor accommodation and a facility to enable four residents to live as independently as possible. Equipment and beds to meet the needs of residents with physical/mobility needs have also been provided. The Manor House is one of three homes within the Manor House Organisation that provides for adults with learning disabilities and a further home is registered with the Commission for Social Care Inspection to provide respite care to children with a learning disability and there is a day centre. Four of the services share the Manor House site. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The inspection was carried out on a Saturday because during the week all residents attend day care activities. Nine residents were consulted to find out their views, and what their experience of daily life is like. Please note due to profound, multiple disabilities, some residents are unable to express their views verbally. Part of the inspection was carried out through discussion with residents and by observing staff carrying out their duties. A senior care assistant and three care assistants were also consulted about their roles and responsibilities, training needs, and how they assist residents. A sample of records relating to the day-to-day running and management of the Home were inspected. Two resident’s care records and care plans were also reviewed. Lunch was sampled in the company of residents. The majority of the environment was viewed in the company of a number of residents who kindly assisted in the inspection. What the service does well: What has improved since the last inspection? Since the last inspection there is evidence that residents plans of care and risk assessments are reviewed at least every six months and residents are involved in the process. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 6 Residents now have an individual record of medication including all short course prescriptions. Some residents now benefit from having a medication profile which details information about resident’s medication. 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 DS0000003354.V273661.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 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 the following standard(s): 2,3 Residents’ needs are assessed and are being met by the Home. EVIDENCE: Residents were observed being supported by understanding and sensitive staff. There was a warmth and sensitivity when residents were assisted by staff. Residents looked relaxed and comfortable in the company of staff. All the residents asked were positive in their views of the staff and the care they provide. Examples of comments residents made included, `the staff are all good,’ `I like it here,’ and, `it’s a nice home’. These comments were reflective of the views of all residents consulted. To find out how residents care needs are assessed two assessment records were inspected. There was an informative assessment in place of resident’s physical, social psychological, and spiritual needs. Residents’ need assessments and care plans are written from a `person centred perspective’. This means assessments and care plans are written from what should be the views and wishes of the resident. The use of this approach should further ensure residents’ views and wishes are central when care needs are assessed. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 9 The assessment information had been regularly reviewed and updated which helps show staff closely monitor residents’ needs. There was also a range of evidence to demonstrate the community learning disability team; the psychiatrist and a behaviour team are supporting residents. This demonstrates resident’s benefit from a multi-disciplinary approach to their care. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 6,9, Residents’ needs are met and care plans help support this. Residents are also well supported to take risks in their daily lives. EVIDENCE: To review how care is provided two residents care plans were inspected. The care plans contained detailed and helpful information about how to support the residents with care needs. Care plans include information about how residents make decisions including how they communicate their needs. Care plans also addressed residents’ psychological needs and how to respond if the resident is distressed or angry. The care plans had been regularly reviewed and updated, demonstrating staff were monitoring residents’ changing needs. Staff explained how residents with limited verbal communication are supported to communicate their needs by using gestures and observing facial expressions. Plans of care detailed residents differing communication needs. The Home also seeks the advice from the speech therapist on a regular basis. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 11 There is also evidence demonstrating residents are well supported by staff to take risks in their daily lives. There were detailed and up to date risk assessments in place that include information about the resident and the range of activities they take part in. Risk assessments clearly stated what to do to minimise any undue risks to residents. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 13,14,17 Residents are provided with a varied well balanced diet, and are supported and encouraged to live a varied and fulfilling life. EVIDENCE: Residents attend a range of day care services and college courses. There are also activities organised in the Home including arts and crafts, games sessions, and cooking groups. During the afternoon a group of residents and staff took part in a music session with a range of musical instruments. Residents looked as if they were very much enjoying this activity. Also a small group of residents went to watch a Bristol Rovers match in Bristol with the support of staff. Another group of residents went out for a drive and for a cup of coffee. Also one resident went out for a walk to the shops. One resident explained that they liked to assist staff around the Home with chores and household activities, and they hoped to undertake paid work. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 13 It is evident residents are well supported to attend their preferred choice of social and therapeutic activities both in the week and at weekends. There are regular residents meeting held. The minutes are accessible and included pictures and symbols. Residents are involved in menu planning, and choosing social activities. The menu record was inspected to ascertain if residents are provided with a well balanced diet. There were choices of dishes recorded and the menu was nutritionally well balanced, and varied. The lunchtime meal was seen being served. The meal consisted of beef goulash and rice or sandwiches. All of the residents who were asked said the food in the Home was very good and satisfactory. It was also observed that residents enjoy a warm relationship with the chef. This is to be commended and it is evident the chef listens to residents and regularly consults them. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 18,19,20 Residents are supported to meet their needs in the way they prefer, and residents’ medication is handled and administered in a way that is mostly safe. EVIDENCE: Residents care plans detailed their personal care needs and how staff should support residents to meet needs. Individual residents’ records include information about how best to monitor epilepsy and staff receive training on epilepsy and administering of rectal diazepam. Care records also detailed how residents prefer to be assisted with a range of personal care needs. There were detailed records in place demonstrating the Home monitors residents wellbeing and concerns about health are promptly addressed. Residents have access to other health professionals including the GP, the optician, chiropodist, dentist and the community learning disability team. Residents are further supported by a weekly visit from the local GP. It was reported that the Home has a good relationship with the surgery. During the morning residents were observed rising at their preferred time. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 15 Staff assisted residents in a good humoured and courteous manner, and residents evidently have built up warm relationships with staff. Staff on duty communicated among each other and worked well as a team. To find out how residents’ medication is being held and administered the procedures for the administration, storage and disposal of medication were reviewed. There was a photograph of the resident maintained with each record to ensure medication is dispensed to the correct person. The medication administration charts were legible, up to date, and contained the signature of the dispensing member of staff. This demonstrates residents’ medication is administered safely. The reasons for any omissions had also been written on the charts. Up to date records are also being kept of all medication being received into the Home, and medication being returned to the issuing pharmacy, showing there are safe systems in place to monitor how much medication is held in the Home. Since the last inspection some residents now benefit from detailed medication administration profiles. These detailed the reason why residents’ medication is administered in a particular way, such as in food. However the content of some of the administration profiles was variable and some were far less detailed and informative and did not satisfactorily explain the reasons for this practice. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 22,23, Residents are protected by the complaints procedure that helps ensure complaints are investigated thoroughly. Residents are protected from harm or abuse. EVIDENCE: A copy of the complaints procedure for residents to make a complaint is on display in a well-frequented part of the Home. The complaints procedure has been written in a user-friendly pictorial format to assist the reader. The procedure includes the contact details for the owners of the Home and the Commission for Social Care Inspection, if someone wants to contact the Commission directly. The complaints record book was not viewed on this inspection. All the residents who were consulted said they felt very able to speak to any the staff if they had concerns or complaints. There are regular residents meetings held. This is an opportunity for residents to express any concerns or complaints they may have. This helps to ensure a culture where residents feel `comfortable’ to complain. There is a policy in place relating to the issue of protection of vulnerable adults from abuse, however this was not reviewed on this inspection. All staff attend training on the issue of `protection of vulnerable adults from abuse’. This should help ensure residents are safeguarded from the risk of harm or abuse. Staff conveyed in discussion that they had a good understanding of the need and importance in upholding resident’s rights. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 17 The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 18 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 the following standard(s): 24,25,26,27,28, 29, 30 Residents live in an environment that is homely, clean, comfortable and suitable for their needs. EVIDENCE: The Manor House is situated in a semi-rural location in Frenchay village in close proximity to the M4 and Avon ring road outside of the City of Bristol. There are shops and facilities within a mile of the Home. The Home is a large detached property that is divided into two sections. Chestnut and Arundel each with its own facilities shared communal space and staff teams. Accommodation is on three floors. There is a lift to the first floor, which is accessible to wheelchairs. Residents with physical and mobility needs are provided with the necessary equipment and beds to meet their needs. There are also appropriate aids and adaptations to support residents and the staff team. This equipment helps promote residents’ independence. The majority of bedrooms were seen and these had been personalised by residents and were furnished to a satisfactory standard. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 19 The Home also provides a more independent living area on the top floor where there is a kitchenette and living room for up to four residents. Residents who live in this part of the Home showed the inspector these facilities and are clearly very happy living in this environment. All of the communal living areas were homely and comfortable. Residents were seen relaxing and looking very settled in their surroundings. The Home was clean and tidy and looked generally satisfactorily maintained. However there were two chipped tiles on the main kitchen wall and two chipped tiles on a shower room wall. These need to be repaired or replaced, to ensure both rooms are safe. The kitchen cupboard doors in Arandal dining area must also be repaired or replaced as they have come off their hinges. There is a separate laundry facility however this was not inspected on this occasion. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 20 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35,36 Residents are supported to have their care needs met by competent wellsupervised staff. EVIDENCE: To find out if sufficient staff are on duty at all times to meet residents needs the staff duty record for shifts worked in February 2006 was inspected. There are a minimum of five staff on duty during the day and the Home aims for seven staff during core hours during the day and at weekends to support residents. There are one waking and two sleep in members of staff covering the night shifts. There is a senior carer on duty at all times. Senior carers are responsible for managing the shifts on a daily basis and administering medication. There are additional staff rostered to provide residents opportunities to go out for social and therapeutic activities. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 21 The training needs of staff were discussed with all the staff the inspector met. All of the staff spoke very positively about the range of training and development opportunities that they are provided with. This helps demonstrate residents are supported by staff who attend training courses and study days relevant to their needs. The staff also told the inspector about the system of supervision that the manager has put in place. They said they are provided with regular supervision sessions. They also said that there are regular appraisals of their work and practice carried out by the registered manager. This should further ensure residents continue to be supported by competent staff who are developed in their work and practice. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 22 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41,42 Generally residents’ health and safety is protected. EVIDENCE: The registered manager takes responsibility for overseeing health and safety matters in the Home. There is also an operational health and safety manager who further protects resident’s health and safety. Staff receive training in a range of relevant health and safety matters to ensure residents are protected and supported. When viewing the environment, it was observed in Chestnut House that there were three bottles of cleaning materials, which can be a health and safety risk if drunk, not being stored securely in accordance with health and safety regulations. The fire logbook was checked and showed weekly tests of fire alarms are carried out. However fire-fighting equipment should be checked on a more regular basis than currently takes place. It is recommended by local fire safety The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 23 officers that fire fighting equipment is checked in the Home on an at least monthly basis. There was a record that staff had attended fire safety update training in the last twelve months to ensure they are aware of fire safety procedures in the Home. The kitchen was inspected to check what systems are in place to ensure safe food handling, storage preparation and serving. The kitchen environment was clean and reasonably well maintained. There were records kept to demonstrate cooks were temperature probing `high risk’ foods prior to being served to residents. There were also up to date records to demonstrate staff monitor the temperatures of the fridges and freezers. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 24 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 Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X X X X 2 X The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 25 No 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 Standard YA24 Regulation 23.2(b) Requirement Timescale for action 01/05/06 2 3 YA24 YA20 23.2(b) 13. (2) The two chipped tiles on the main kitchen wall and the two tiles cracked on the shower room wall must be repaired or replaced. The kitchen cupboard doors in 01/05/06 Arandal dining area must be repaired or replaced. Ensure that all medicine 01/04/05 administration profiles are sufficiently detailed to satisfactorily explain the reasons for administration of medications in foods such as yoghurt. 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 YA42 Good Practice Recommendations Fire fighting equipment should be checked on a monthly basis in accordance with the fire safety officers’ recommended guidelines. The Manor House DS0000003354.V273661.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 DS0000003354.V273661.R01.S.doc Version 5.1 Page 27 - 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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