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 March 2006 16:00 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 Nursing Home DS0000001102.V255493.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 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.V255493.R01.S.doc Version 5.1 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 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.V255493.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Elderly patients over 60 years of age Date of last inspection 20th December 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. There is plenty of car parking and the home is on a bus route. 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.V255493.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. This was the second unannounced visit to the home. There have been no further visits to the home until this inspection. One inspector carried out the inspection and spent approximately four hours at the home. The purpose of this inspection was to assess the home against a predetermined selection of the National Minimum Standards for Older People. The methods used included conversations with residents and staff, examination of records, and a partial tour of the house. This short inspection was to assess the key standards which were not inspected in December 2005, and assess progress in meeting the one good practice recommendation from that inspection. One good practice recommendation has been made following this inspection. I would like to thank everyone who lives and works at The Manor House Nursing Home for their welcome and hospitality during the inspection. What the service does well: What has improved since the last inspection?
The home’s manager has started developing social and leisure interest profiles for all the people who live at The Manor House Nursing Home. They are being written with the service users and their relatives. Although the process had not been completed by this inspection significant progress had been made and useful information gained.
The Manor House Nursing Home DS0000001102.V255493.R01.S.doc Version 5.1 Page 6 The former dining room has now been converted to make two single bedrooms. One ground floor twin room was in the process of being divided to form two single rooms. 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.V255493.R01.S.doc Version 5.1 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.V255493.R01.S.doc Version 5.1 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): Standard 3 was assessed in December 2005. None of the other standards were assessed at this inspection. Standard 6 does not apply. EVIDENCE: The Manor House Nursing Home DS0000001102.V255493.R01.S.doc Version 5.1 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): Standards 7, 8, 9 & 10 were assessed in December 2005. The other standard was not assessed at this inspection. EVIDENCE: The Manor House Nursing Home DS0000001102.V255493.R01.S.doc Version 5.1 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 Standards 12, 13, 14 & 15 were assessed in December 2005. Service users personal social profiles are in the process of being developed. EVIDENCE: The home’s manager has started developing personal social and leisure interest profiles of all the service users, so that staff will have a fuller understanding of the people who live at the home. They will also be able to draw on this information to support service users to pursue their interests, if they wish. The manager has been involving service users and their relatives in this process and expects to have the profiles completed in the near future. The Manor House Nursing Home DS0000001102.V255493.R01.S.doc Version 5.1 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 Standard 18 was assessed in December 2005. The complaints procedure contains all the necessary information. EVIDENCE: The home’s complaints policies and procedures includes all the necessary information to inform a service user or their representative about how to make a complaint and how it will be handled. The Manor House Nursing Home DS0000001102.V255493.R01.S.doc Version 5.1 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): Standards 19, 20, 22 & 26 were assessed in December 2005. None of the other standards were assessed at this inspection. EVIDENCE: The Manor House Nursing Home DS0000001102.V255493.R01.S.doc Version 5.1 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): Standards 27, 28, 29 & 30 were assessed in December 2005. EVIDENCE: The Manor House Nursing Home DS0000001102.V255493.R01.S.doc Version 5.1 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): 33 & 38 Standards 31 & 35 were assessed in December 2005. EVIDENCE: The quality assurance systems used by The Manor House were discussed. The home has an annual development plan and the owners and management continually monitor the quality of the care and support they offer. Service users and their relatives are asked to give their views on the home and this information is used to help improve the quality of care and accommodation that is offered. Staff should make sure that all service users’ personal files are securely stored when not in use. The kitchen is clean and hygienically maintained and daily records are kept of the refrigerator, deep freezer and cooked food temperatures. Regular health
The Manor House Nursing Home DS0000001102.V255493.R01.S.doc Version 5.1 Page 15 and safety checks, such as the gas appliance service and safety checks, were seen to be carried out. The house, grounds and equipment are well maintained and the premises are safe and secure. Any accidents or injuries are recorded and dealt with appropriately. The Manor House Nursing Home DS0000001102.V255493.R01.S.doc Version 5.1 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 The Manor House Nursing Home DS0000001102.V255493.R01.S.doc Version 5.1 Page 17 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 The social profile and more detailed record of each service user’s interests should be completed. The Manor House Nursing Home DS0000001102.V255493.R01.S.doc Version 5.1 Page 18 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
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