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Inspection on 20/12/05 for The Manor House Nursing Home

Also see our care home review for The Manor House Nursing Home for more information

This inspection was carried out on 20th December 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home`s pre-admission assessments and plans for each individual`s health and personal care are comprehensive and clearly direct the way each person`s care is to be provided. The medications are administered, recorded and stored safely with attention given to accuracy within the system. Service users are treated with respect and their dignity is maintained. Everyone who commented said how good the care is and that the staff are very kind. The menus offered are varied and offer plenty of choice. Service users told me they enjoy their meals and look forward to them. The house and grounds are well maintained with plans underway for further improvements to the home. The new conservatory, which is used as a lounge, is an attractive and comfortable place to sit. Service users told me how much they like the room. The home`s recruitment procedures are robust with all the necessary safety checks in place.

What has improved since the last inspection?

The plans of care show improvements in the way the service users` personal care needs are recorded and care plans developed. Consultations with the service user or their representative about how the individual`s care needs will be met are now recorded. Seven of the eleven care staff have now achieved a National Vocational Qualification (NVQ) level 2 qualification in care. This means the home has now exceeded the minimum requirement of having 50% of qualified care staff.

CARE HOMES FOR OLDER PEOPLE The Manor House Nursing Home 127 Wakefield Road Lightcliffe Halifax West Yorkshire HX3 8TH Lead Inspector Liz Cuddington Unannounced Inspection 20th December 2005 13:45 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 Nursing Home DS0000001102.V254673.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 Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Manor House Nursing Home Address 127 Wakefield Road Lightcliffe Halifax West Yorkshire HX3 8TH 01422 202603 01422 204113 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 Jean Thomas Mr Brian Victor Binns Mrs Angela Charlesworth Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Elderly patients over 60 years of age Date of last inspection 20th January 2005 Brief Description of the Service: The Manor House Nursing Home is a well-run and comfortable home providing nursing care for up to 31 service users. It is set in its own attractive, well kept grounds with pleasant outside seating for service users and their guests to use in the better weather. The bedrooms are a mix of single and shared rooms and the communal rooms are spacious and attractive. A new conservatory lounge has recently been completed. The home is well furnished and kept in good decorative order. The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Once again this was a good inspection, with one good practice recommendation and no requirements being made. During the inspection, which took place during an afternoon and early evening, I spoke with a number of service users and staff. All the comments I received were positive, with service users saying how satisfied they are with the care and accommodation at The Manor House Nursing Home. I would like to thank all the people who live at the home, the staff and the management for their welcome and hospitality during the inspection. What the service does well: What has improved since the last inspection? The plans of care show improvements in the way the service users personal care needs are recorded and care plans developed. Consultations with the service user or their representative about how the individual’s care needs will be met are now recorded. Seven of the eleven care staff have now achieved a National Vocational Qualification (NVQ) level 2 qualification in care. This means the home has now exceeded the minimum requirement of having 50 of qualified care staff. The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Manor House Nursing Home DS0000001102.V254673.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 Nursing Home DS0000001102.V254673.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): 3 Standard 6 does not apply Pre-admission assessments are carried out to ensure new service users needs can be met. The plans of care are based on these assessments. EVIDENCE: A number of plans of care were examined. They showed that all the necessary pre-admission assessments are carried out to make sure that the home can meet the prospective service user’s needs. The individual care plan is based on these assessments. A qualified nurse assesses the nursing needs of each service user. The Manor House Nursing Home DS0000001102.V254673.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, 8, 9 & 10 The plans of care contain all the necessary information to enable the staff to provide the personal care and healthcare needed by each service user. The medications are stored and administered safely. Staff treat service users with respect and their dignity is maintained. EVIDENCE: The service users individual plans of care, which I examined, showed that there has been an improvement since the last inspection. The moving and handling plans contain more detail and there is evidence that service users, or their representatives, are involved in drawing up and reviewing their plan of care. Monthly evaluation sheets are completed and show that the staff review the plans regularly to make sure they still meet the service users needs. There is a separate file containing the service users risk assessments. These assessments are referred to in the relevant section of the individual plans. The plans include evidence that all areas of each individual’s healthcare are recorded and appropriate care and treatment is provided. Specialist healthcare professionals, such as the Tissue Viability Nurse, are consulted on an The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 Page 10 individual’s care and staff are advised how to treat particular conditions. Healthcare assessments are carried out regularly. The medication administration systems were inspected and all the records I saw were accurately kept. Medicines are stored securely and handled in accordance with the Royal Pharmaceutical Society’s guidance. From my observations, and from comments made by service users, the staff treat service users with respect and people’s dignity is respected and maintained. Medical examinations take place in service users own rooms. Privacy screening is provided, and used, in the shared bedrooms. The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 & 15 More detailed records of service users social and leisure preferences would enable staff to expand the range of activities and support offered. Visitors are made welcome. Accurate records of chargeable expenses are kept. The meals are varied and there is a wide choice available. EVIDENCE: Activities are noted in service users care plans. The home’s staff support service users, where needed, to continue with their interests both within and outside the home. The inclusion of a social profile, or a more detailed record of interests, in the individual care plans may help staff to focus on providing further activities and support to meet people’s particular preferred leisure and social activities. Visitors are always welcome and the service users are able to use either one of the lounges or their own rooms when they have visitors. The system for paying people’s personal allowances has been changed by Calderdale MBC and the home no longer handles any money on behalf of service users. Accounts are sent out for chargeable expenses such as chiropodist treatment, hairdressing and newspapers. Accurate records of these The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 Page 12 transactions are kept. The home keeps details of advocacy services, should a service user or their family wish to contact an advocate. There is a good choice of dishes at mealtimes. On the day of the inspection the teatime menu included jacket potatoes, cheese on toast, soup and sandwiches. I saw references to individual food preferences in service users care plans. Special diets are catered for. The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 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 the following standard(s): 18 Robust systems for dealing with allegations of any type of abuse are in place. EVIDENCE: The home’s policies and procedures about adult protection include reference to Social Services’ Adult Protection Officer. The policies and procedures show clearly how any allegation of abuse, ill treatment or neglect would be handled. The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 22 & 26 The grounds, building and furnishings are well maintained. Good hygiene and infection control systems are in place. EVIDENCE: The grounds are well maintained and there is a pleasant outdoor seating area which people use when the weather is warm enough. The building is kept in good order and is well decorated and furnished. A new conservatory has recently been completed. This is being used as a lounge and the service users who commented said they found the room very pleasant and comfortable. There is a ramp at the main entrance and a new ramp has been made, which leads into the garden from the decked area at the back of the conservatory. There are grab rails and other adaptations to assist with mobility and independence, throughout the home. The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 Page 15 The house is very clean and hygienically maintained throughout. The laundry is properly equipped and infection control measures are in place throughout the home. The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 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 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, 28, 29 & 30 The staff recruitment procedure is robust and suitable training is available. EVIDENCE: The staff rotas show that there are sufficient numbers of suitably skilled staff on duty to provide the proper level of care to meet the needs of the service users. Eleven care staff are employed and seven of these have achieved their NVQ level 2 qualification in care. Two staff have their NVQ level 3 qualification in care. Staff files were examined and they include all the necessary documentation listed in Schedule 2 of the Care Homes Regulations 2001. The files show that the recruitment process is robust and all the required pre-employment checks are carried out. These include obtaining a new Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register check, as well as two suitable references when a new member of staff is recruited. New staff undertake induction and foundation training and are also expected to take an NVQ qualification in care, if they do not already have one. Additional training is arranged to keep staff skills and knowledge levels up to date. The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 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 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 & 35 The home’s manager is suitably qualified and experienced. Service users finances are not handled by the home. EVIDENCE: The registered manager is a qualified and experienced nurse who also has a management qualification. The manager has many years care and management experience and undertakes further training to keep her skills and knowledge levels updated. As mentioned previously the home no longer handles any monies belonging to service users. The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 Page 18 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 3 X X N/A 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NO 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. 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. Refer to Standard OP12 Good Practice Recommendations A social profile and more detailed record of each service user’s interests would assist staff in supporting service users to pursue leisure and recreational activities, if they choose. The Manor House Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Nursing Home DS0000001102.V254673.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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