Inspection on 14/02/07 for The Manor House (Residential)

This inspection was carried out on 14th February 2007.

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.

Other inspections for this house

The Manor House (Residential) 09/01/09

The Manor House (Residential) 20/03/06

The Manor House (Residential) 20/12/05

The Manor House (Residential) 07/03/05

The Manor House (Residential) 01/09/04

The Manor House (Residential) 25/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Manor House (Residential) 127 Wakefield Road Lightcliffe Halifax West Yorkshire HX3 8TH Lead Inspector Cheryl Stovin Key Unannounced Inspection 14th February 2007 10:00 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 (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 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 (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House (Residential) 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 Jean Thomas Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th March 2006 Brief Description of the Service: The Manor House Residential Home is a family run home providing care and accommodation for up to thirty older people in a warm and friendly environment. The home is set in its own extensive grounds within walking distance of a bus route. There is plenty of car parking available. There are two light and airy lounges and a comfortable dining room. The majority of the bedrooms are single rooms and the home is well looked after and attractively decorated. There is a very pleasant outdoor seating area overlooking adjacent fields. The surroundings of the house and entrance are made attractive and welcoming with numerous flower filled tubs. The weekly charges at the home range from £323 to £360. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report brings together evidence gathered during a key inspection of The Manor House Residential Home. This included an unannounced visit I made to The Manor House on 14th February 2007. During this visit records were examined and discussion took place with management and staff. All areas of the home were seen. In addition to this visit comment cards were sent out to the service users and relatives/visitors to give people an opportunity to share their views of the service with CSCI. Five service user surveys were returned, and eighteen relatives/visitors replied. The last inspection of The Manor House was on 20th March 2006. No additional visits have been made to the home. A pre-inspection questionnaire was not sent to the home, but the information required was made available during the visit. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk What the service does well: The home has a relaxed and welcoming atmosphere and service users and visiting relatives I spoke to during the inspection confirmed that this is always the case. All service users are subject to assessment before to moving into the home, and are encouraged to visit, several times if they wish, before making a decision to move in. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 6 The staff are working together as a team and meeting the needs of the service users in a sensitive and dignified manner, with appropriate use of informality and humour. The service users said they were well treated and that the staff are kind and attend to their needs promptly. Relationships between fellow service users appeared cordial and it was apparent that friendships had been formed. The standard of the food was described as “excellent” by service users during the visit. The home is generally well maintained throughout and service users expressed satisfaction with the communal areas and their own private accommodation. Service users and visitors confirmed that standards of cleanliness and hygiene are always of a high standard. All eighteen of the relative/visitors comment cards received indicated that they were satisfied with the overall care provided within the home. What has improved since the last inspection? What they could do better: The service users’ care plans must contain more detail about the actions to be taken to meet each assessed need. It would also be useful for the care plans to contain information about the service users’ previous lifestyles and interests. Staff recruitment practices and procedures must be strengthened to protect the service users. Pre-employment checks must be carried out. A Criminal Records Bureau and Protection of Vulnerable Adults disclosure must be received. Two written references must also be obtained for each new member of staff. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 7 The staff team must continue working towards 50 of the staff being qualified to NVQ level 2 or equivalent to ensure the high standard of care is maintained. The general manager of the home should submit an application to the CSCI to registered as manager of the home. 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 summary of this inspection report can be made available in other formats on request. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 8 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 (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assessed before moving into the home to make sure the home can meet their needs. EVIDENCE: The home has a statement of purpose and service user guide which contains details of the services and facilities provided in the home which helps prospective service users to make a decision about moving in. All of the service users have an assessment before moving into the home to make sure their needs can be met. Prospective service users are also encouraged to visit the home to meet the staff and fellow service users and to sample the daily routine within the home. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 10 One relative/visitor who completed a comment card said: “we had full information about the home including past inspection reports which helped us make the decision about what home to choose”. Service users have a contract which sets out the rights and responsibilities of each party. Which means service users are informed of their rights. Intermediate care is not provided in the home. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and health care needs are met. Service users are protected by the medication practices in the home. EVIDENCE: All service users have an individual plan of care. The care plans contain basic information about the assessed needs of the service users, but not much detail as to how the care is actually to be delivered. No information is recorded about the service users’ background or their previous interests. There is no suggestion that the service users’ needs are not being met, but how the care is to be provided needs to recorded in more detail. Service users spoken to confirmed that they receive the care and support they need. All of the relatives/visitors comment cards indicated that the home always gives the The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 12 support and care to their relative that they expect. Additional comments made included: “We find the present care and support to be of a high level”. “The care and support is tailored to personal needs”. “The care home is meeting all of the needs of my Mother”. “I find the actions of the staff to be of a level that gives confidence of their abilities to give proper care”. “My Mother is obviously well looked after and her needs catered for”. “Given the way the home is manager I can be confident that different needs would certainly be met”. “They attend promptly to any medical problems and keep the family well informed”. “They know my Mother’s needs and respect her wishes at all times”. The home uses a Monitored Dose System (MDS) for the administration of medication. The medication is securely and appropriately stored in a medication room. Medication administration records were accurately completed and stocks of medication reconciled with records held. All staff responsible for handling medication have received training to make sure medication is handled safely. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines within the home are flexible and service users are enabled to exercise choice and control over their lives. Service users enjoy a varied and nutritious diet. EVIDENCE: The daily routines in the home are flexible to enable the service users to exercise choice as to how, where and with whom they spend their time. Service users confirmed that they choose when to get up and when to retire. A range of activities are provided for the service users to join in with if they wish. Service users stated that they particularly enjoy the visiting entertainers. The service users who completed a comment card stated that there are always activities arranged by the home that they can take part in. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 14 One made the additional comment: “when activities are arranged I am assisted into the common rooms so I may take part or watch”. Visiting relatives, spoken to during the inspection, confirmed that they were always made to feel welcome when they visit and are kept informed of any issues affecting their relatives’ welfare. All of the respondents to the relative/visitor comment cards indicated that they are kept up to date with important issues affecting their friend/relative. Additional comments made included: “Contact with the home is good the manager rings frequently to keep us informed”. “We are promptly informed of any incidents and accidents and what actions have been taken and need to be taken”. “Always notified, doctors visits also notified along with diagnosis/treatment”. Service users spoken to confirmed that they enjoyed the meals provided in the home. The main meal of the day is served at lunchtime and the luncheon being served during the inspection was: roast pork with stuffing and apple sauce, sprouts, creamed potatoes and cauliflower au gratin, followed by apple crumble and custard or milk pudding. The meals are served in a pleasant environment with tables attractively set. Vegetables are served from tureens on the dining tables. Special diets are catered for and service users requiring assistance are helped in a dignified manner. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the policies and practices within the home. EVIDENCE: The home has a complaints procedure which is displayed on the notice board in the entrance to the home. All of the service users who returned a comment card knew who to speak to if they were unhappy about anything in the home and all of the relative/visitors comment cards received indicated that they knew how to make a complaint, with the following additional comments: “Very positive responses to any concerns raised”. “We have been given verbal information. Notices are displayed in an area which is accessible to residents and visitors. (Notice board outside the office”. “Yes, but couldn’t imagine having to make a complaint about this home!”. The home has an adult protection procedure in place and staff receive training in the Protection of Vulnerable Abuse. A ‘whistle blowing’ procedure is in place The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 16 and staff are aware of the procedure to follow if they witness or suspect that abuse is occurring. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, clean and well maintained environment. EVIDENCE: The home is situated in the Lightcliffe district of Halifax. The accommodation is spacious and set in well maintained safe and accessible grounds. The home is well maintained throughout with a routine programme of refurbishment. Service users’ bedrooms are well furnished and equipped and the majority are highly personalised reflecting individual interests and tastes. The communal areas are spacious and comfortable. The home was noted to be clean and hygienic throughout. One relative/visitor made the following comment: The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 18 “Offers clean, well maintained and very pleasant accommodation and surroundings”. All areas of the home are accessible to the service users and there is a passenger lift. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a well trained and motivated workforce. Staff recruitment practices do not sufficiently protect the service users. EVIDENCE: From records seen and following discussion during the visit sufficient staff are deployed to meet the needs of the service users. There are three care staff plus the management team on duty during the day and two waking night staff. In addition catering, domestic and administrative staff are also employed. Staff spoken to confirmed that they work as a team and felt that there was sufficient time to sit and talk to the service users. Staff were seen to be treating the service users in a sensitive manner and promoting respect and dignity. All new staff receive induction training to Skills for Care Council specification. There is a programme of NVQ training in place and the home is working towards the requirement for at least 50 of the care staff to be qualified to NVQ level 2. It is an expectation that all staff will complete the NVQ award. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 20 Service users comment cards indicated that they felt that the staff listen and act on what they say. Relative/visitor comment cards received expressed satisfaction with the staff with the additional comments made: “Can only comment that staff always appear efficient, attentive and caring at all times”. “Are attentive to specific and individual needs of the people in their care. They ensure that family and relatives are confident that their care is of the highest standards”. “Has very ‘hands on’ owners who genuinely seem to take an interest in each client and their family”. “Staff are experienced and helpful and residents are treated with respect”. “Residents maintain their dignity despite their individual difficulties, mainly because of the caring attitude of all staff at The Manor House”. “The staff give my Mother the support to live life as she chooses”. “They give 24 hour care and support to my Mother thereby giving her a safe environment and quality of life which I believe could not have been otherwise achieved”. “When visiting the care home I find the actions of the staff to be of a level that gives confidence of their abilities to give proper care”. “The care and consideration of care staff has always been good”. “Seem to be good and caring”. A selection of staff records were seen. Some files did not contain evidence of all the required checks being carried out prior to commencing working at the home. Some files did not have a Criminal Records Bureau (CRB) disclosure, some did not have Protection of Vulnerable Adults (POVA) checks and some did not have two written references. One CRB disclosure held on one file did not have the correct name on it, the name was similar but was not spelt correctly. One staff file only contained details of name and address and bank account details. The manager stated that she didn’t think it necessary as the member of staff also works for another employer who had already carried out the checks and taken up references. Recruitment practices and procedures must be strengthened to protect the welfare of the service users. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the service users. The health and safety and welfare of the service users is protected by the home’s policies and procedures.. EVIDENCE: The Registered Manager of the home is experienced and competent to run the home. She dictates a clear sense of leadership and is committed to ensuring an open and positive atmosphere is prevalent in the home. She does not hold an NVQ level 4 in management and care. The general manager of the home The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 22 has, however, recently completed the NVQ level 4 Registered Managers Award and will be applying to become registered as manager. The home places a high priority on health and safety procedures and practices. Detailed policies and procedures are in place. All staff receive training in health and safety and safe working practices. Certificates were seen indicating compliance with all gas, electrical and water regulations. The quality of care given to the service users is constantly monitored to ensure that the standards of care remain high. All staff receive regular supervision, records seen indicate that recorded supervision session take place six times per year. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 23 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x 3 3 3 3 The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 24 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 Standard OP7 Regulation 15 Requirement The service user plan must set out in detail the action which needs to be taken by care staff to ensure that all aspects of health and personal care are met. A minimum of 50 of the care staff must be qualified to NVQ level 2 or equivalent. Pre-employment CRB and POVA disclosures must be received and two written references obtained. Timescale for action 30/04/07 2 3 OP28 OP29 18 19 31/12/07 31/03/07 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 OP31 Good Practice Recommendations The general manager should submit an application to be registered as manager of the home as soon as possible. The Manor House (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 (Residential) DS0000001006.V315087.R01.S.doc Version 5.2 Page 26 - 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!