Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 30/01/06 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 30th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 offers a high standard of nursing care to each individual in a compassionate manner. Residents expressed their sincere gratitude to the staff for the way in which they are looked after and respected. The staff are fully trained in palliative care practices and there were many `Thank you` cards from relatives and friends displayed on the nurses station. The GP in the home at the time of the visit was also very complimentary about the staff and their ability to care for the residents.

What has improved since the last inspection?

There are few changes since the last inspection. No requirements were made. The Laundry has had a new drier fitted that has assisted the laundress in her duties.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE The Manor House Nursing Home Hyde Lea Stafford Staffordshire ST18 9AT Lead Inspector Mrs Joanna Wooller Unannounced Inspection 30 January 2006 12:05 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 DS0000022349.V279410.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 DS0000022349.V279410.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Manor House Nursing Home Address Hyde Lea Stafford Staffordshire ST18 9AT 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) 01785 241351 01785 251824 cleaver42@hotmail.com Hyde Lea Nursing Home Limited Mrs Kathleen Ann Cleaver Care Home 43 Category(ies) of Physical disability (43), Physical disability over registration, with number 65 years of age (43), Terminally ill (4) of places The Manor House Nursing Home DS0000022349.V279410.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Thirty one PD Minimum 60 years of age on admission 12 PD to be accommodated in designated unit of which six PD- may be intermediate care 16th August 2005 Date of last inspection Brief Description of the Service: Manor House is a 43-bed care home, which offers 24 hour nursing care. The house is in a rural area on the outskirts of Stafford town. It has a bus route close by. Set in its own grounds, the service users enjoy a very attractive view from all sides of the home. The home is owned by Hyde Lea Nursing Home Limited, and Managed by Mrs Kathleen Cleaver, a Registered Nurse with a wealth of knowledge and experience. A registered nurse is on duty 24 hours a day and the home is also staffed with well-trained carers and experienced ancillary staff. Four of the beds are registered for palliative care service users, six beds are designated to intermediate care services and four other beds are registered for service users between the age of 18 and 60yrs who have physical disabilities. The home is split on two levels with bedrooms upstairs and down. First floor access is available via two passenger lifts and stairs. There are several lounges within the home, at the rear of the building is a large airy lounge which has a smaller cosy lounge situated to the side of the area. The dining room is situated within the beautiful conservatory. There are 31 single and two double bedrooms. All bedrooms (except one) have en-suite facilities, which include WC and sink. The environment improvements have been completed to a high standard. The Manor House Nursing Home DS0000022349.V279410.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The lead inspector carried out this unannounced inspection. The manager was not in the home and the Deputy care manager was in charge of the morning shift. There was a peaceful ambiance throughout the home and a pleasant atmosphere with residents going about their usual routines supported by carers and nurses. No issues relating to complaints had been received by the CSCI or issues of abuse reported. Staffing was found to be in order and a full team of permanent staff worked in the home. The visit was uneventful and all requests from the inspectors were met. What the service does well: What has improved since the last inspection? There are few changes since the last inspection. No requirements were made. The Laundry has had a new drier fitted that has assisted the laundress in her duties. The Manor House Nursing Home DS0000022349.V279410.R01.S.doc Version 5.1 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 DS0000022349.V279410.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 DS0000022349.V279410.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): 1,2,4,5 Prospective service users have the information they need to make an informed choice about where to live and this is available in the Statement of Purpose. Each service user has a signed contract, which confirms their needs will be met whilst in the home. EVIDENCE: It is evident to the inspector that the staff individually and collectively has the skills and experience to deliver the services and care which the home offers to provide. Prospective residents are given the opportunity for staff to meet them in their own homes or current situation and they are welcome to visit the home on a trial basis. The statement of purpose and service user guide is available for all to read and discuss at any time. Information is changed and updated as necessary. Each resident has a written contact with the home and it is confirmed in writing that his or her individual needs will be met at the home. The Manor House Nursing Home DS0000022349.V279410.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): 7,8 Resident’s health care needs are identified and evidenced as being met within care records. EVIDENCE: Care staff at the home maintain the personal and oral hygiene of each resident and support their individual self-care capacity. Individual health care needs are identified in individual care plans and reviewed monthly. Short-term care plans are introduced in some circumstances to ensure closer assessment of the residents’ condition. Access to NHS services is made available to all residents and this is recorded in the care records. The chiropodist was in the home at the time of the visit. Care records and monthly observation charts were well documented and up to date. Several cot side risk assessments were found not signed and this must be completed as soon as possible. The Manor House Nursing Home DS0000022349.V279410.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, 15 Service users are encouraged to maintain contact with all family, friends and community links whilst in the home. Wholesome and appealing meals are cooked in the home and service users benefit from exercising choice and preferences, which are documented. EVIDENCE: The residents benefit immensely from the enthusiastic input given by the homes activity coordinator. She is knowledgeable in the art of social care and recreational activities for all the service users. Service users spoken to enjoy the input and say the balance is just right. During the inspection visit many service users were eating lunch but there were notice boards evident throughout the home with events photographs and thank you letters. Visitors are welcome at any reasonable time and visitors were evident during the visit. Those spoken to said they felt content with the care that their relatives received and they always felt welcome on arrival to the home. The Manor House Nursing Home DS0000022349.V279410.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): 16,18 The staff give residents and their representatives strong assurances that their complaints or concerns will be listened to. Protection from abuse training is given to all care staff. EVIDENCE: No incidents of neglect or abuse of any kind has been reported. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. Inspection of the complaints book, the relevant policy and procedure documentation, and a discussion with staff and service users, evidenced that any complaints would be listened to and dealt with in the correct manner. Since the last inspection no complaints had been recorded or brought to the attention of this commission. The inspector evidenced many lovely ‘thank you’ and complimentary cards which were sent from appreciative relatives. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and on-going supervision. The Manor House Nursing Home DS0000022349.V279410.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): 19,26 The service users do live in a clean, safe and well-maintained environment. Specialist equipment to assist individuals is available as required. EVIDENCE: The environment of the home was found to be exceptionally clean, hygienic and tidy in all areas inspected. The home had evidenced that it is well maintained, with an excellent maintenance folder of records available to demonstrate this. Each service user is able to personalise their bedroom as they so wished and there was evidence that this is appreciated. Specialist equipment is evident in the home and within the maintenance folder as being well maintained. Pressure relieving mattresses in varying forms are on each bed in the home. A mattress audit is undertaken at least annually. The Manor House Nursing Home DS0000022349.V279410.R01.S.doc Version 5.1 Page 13 Independence is encouraged and promoted throughout the day with assistance given as required. Communal areas are light and airy with varying seating arrangements. The dining areas are also in a designated area; tables are laid with cloths and flowers that are appealing to the eye. A new nurse call system had recently been fitted in all service users areas and this was seen as a big improvement, along with the cordless telephone system, which had also been recently installed. The Manor House Nursing Home DS0000022349.V279410.R01.S.doc Version 5.1 Page 14 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): 27,30 The carefully recruited staff that are suitably trained and professional in their manner meet the residents needs. EVIDENCE: Staffing levels are monitored to ensure that the needs of the service users can be met. Staffing rota’s were made available for the inspector as evidence of staffing levels and staff competence. Most of the staff are first aid trained and have a food hygiene qualification. Two to three trained nurses are on duty for each shift, supported by care staff. Each trained nurse has a responsibility to a specialist subject such as continence and wound care. This link nurse role promotes current good practice within the home. A robust recruitment procedure is in place, which demonstrates the managers’ commitment to employing and developing highly qualified and professional staff. Staff training is recorded and monitored and was evidenced as appropriate to the care setting. The Manor House Nursing Home DS0000022349.V279410.R01.S.doc Version 5.1 Page 15 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, 36, 38 The home is run and managed for the benefit of the service users. The staff are suitably supervised and they and the service users are safeguarded by the policies and procedures in home. The health, safety and welfare of service users and staff are promoted. EVIDENCE: It was evident whilst in the home that the home is run in the interest of the service users. Staff and relatives confirmed that the service users wishes and choices are promoted within the home. Service users spoken to felt that they felt secure in the home and they belonged there. Financial issues were all satisfactory and policies and procedures protected service users financial interests. The Manor House Nursing Home DS0000022349.V279410.R01.S.doc Version 5.1 Page 16 The ethos and leadership within the home is positive and open. The manager and her team are highly thought of by service users and their relatives/representatives. Staff supervision is in place but had lapsed in the last six months. There was no evidence available for the inspector relating to Staff meetings and this must be addressed as soon as possible. The health, safety and welfare of staff and service users is promoted `and protected by the rigorous testing, recording and monitoring of systems within the home. The maintenance person maintains the home in a professional manner and the records seen by the inspector evidence this. The Manor House Nursing Home DS0000022349.V279410.R01.S.doc Version 5.1 Page 17 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 3 3 X 4 4 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X X X 3 X X 2 The Manor House Nursing Home DS0000022349.V279410.R01.S.doc Version 5.1 Page 18 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. 1 2 Standard OP38 OP36 Regulation 13(4) 18 (2) Requirement Risk assessments must be completed and signed for use of cot sides Staff must be appropriately supervised Timescale for action 28/02/06 28/02/06 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 32.4 Good Practice Recommendations Staff must attend staff meetings that are documented. The Manor House Nursing Home DS0000022349.V279410.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 DS0000022349.V279410.R01.S.doc Version 5.1 Page 20 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!