CARE HOMES FOR OLDER PEOPLE
The Manor House (Residential) 127 Wakefield Road Lightcliffe Halifax West Yorkshire HX3 8TH Lead Inspector
Liz Cuddington Unannounced Inspection 20th December 2005 13:40 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.V254675.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 (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 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 Mr Brian Victor Binns 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.V254675.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th March 2005 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 and the surroundings of the house and entrance are made attractive and welcoming with numerous flower filled tubs. The Manor House (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a very good inspection reflecting the high standard of care and accommodation provided at The Manor House Residential Home. One statutory requirement and one good practice recommendation were carried forward from the last inspection in March 2005. Two further recommendations have also been made. During the inspection, which took place during an afternoon and evening, I assessed eighteen of the thirty-eight National Minimum Standards. I also had conversations with a number of service users, visitors and staff. I would like to thank all the people who took the time to talk to me and made me welcome. What the service does well: What has improved since the last inspection? What they could do better:
The service users plans of care still do not show evidence that, wherever possible, the individual or their representative has been involved in developing and reviewing the plan. The Manor House (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 Page 6 The manager of the home, although very knowledgeable and experienced, should also have a management and care qualification. Three of the eleven care staff have achieved NVQ level 2 in care. The two staff who are working towards this qualification need to complete the course as soon as possible and more staff should enrol. The programme for fitting covers to the radiators is still to be completed. Although progress has been made, there are still a number of unprotected radiators in the communal areas 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 Manor House (Residential) DS0000001006.V254675.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 (Residential) DS0000001006.V254675.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. The Manor House (Residential) DS0000001006.V254675.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 & 10 Not all the plans of care show evidence of the service user’s or their representative’s agreement. Individual healthcare needs are met and professional advice sought where necessary. The people who live at the home are treated with respect and their privacy is maintained. EVIDENCE: The service users plans of care show how each person’s care and support needs are to be met. The plans are reviewed and updated where necessary. Some of the plans show evidence that the service user and/or their representative has been involved in drawing up and reviewing the care plan. All the plans need to be developed and reviewed with the agreement of the service user or someone, such as a relative, who is authorised to speak on their behalf. If this is not possible then the plan should show this and the person’s social worker, reviewing officer or advocate should be involved when a new plan is developed or when significant changes need to be made. The plans of care show clearly how each individual’s healthcare needs are to be met. Observation and conversations during the inspection confirmed that
The Manor House (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 Page 10 people’s healthcare is given all the necessary attention. Specialist healthcare professionals, such as the tissue viability nurse, are involved when needed. From conversations and my own observation the people who live at The Manor House are treated with consideration and respect and their privacy and dignity is maintained. The Manor House (Residential) DS0000001006.V254675.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 Service users are able to make personal choices about their daily lives. Financial transactions are accurately carried out. Mealtimes are leisurely and assistance is available if needed. EVIDENCE: The people who live at The Manor House told me they can choose the routines of their daily lives. Social activities are available according to individual preferences. Visitors were seen to be made welcome. The system for paying people’s personal allowances has changed in Calderdale 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 transactions are kept. The home keeps details of advocacy services, should a service user or their family wish to contact an advocate. Service users bedrooms are made personal with their own possessions, as well as the furniture provided by the home. Three main meals, as well as supper and drinks throughout the day, are offered. Mealtimes are unhurried and staff are available to assist anyone who needs some help.
The Manor House (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 Page 12 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 (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 Page 13 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, 25 & 26 The grounds, building and furnishings are well maintained. A small number of radiators still need to have protective guards fitted. 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. The programme of making and fitting guards to the radiators is nearing completion, with just a few radiators in the communal areas of the home to be covered. 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 (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 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, 28, 29 & 30 The staffing levels are sufficient to meet the needs of the service users. The home has not yet reached the minimum standard of 50 of care staff with an NVQ qualification in care. The staff recruitment procedure is robust and suitable training is available. EVIDENCE: Staff rotas were examined and they showed that there are sufficient care and anciliary staff on duty to meet the needs of the service users. The home employs eleven care staff. Three care assistants have achieved NVQ levels 2 and 3 in care and one has NVQ level 2 in care. One staff member who already has an NVQ level 2 in care has nearly completed the level 3 course. One other member of staff has almost completed the NVQ level 2 course. More staff need to complete an NVQ qualification in order for the home to meet this standard. 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 a new Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register check as well as two suitable references. The Manor House (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 Page 15 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 (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 Page 16 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 The home has an experienced manager, although she does not have a qualification in care and management. Service users finances are not handled by the home. Staff supervision sessions are to begin in January 2006. EVIDENCE: The registered manager, Mrs Thomas, is very experienced and knowledgeable about all aspects of providing care and support for older people in a residential setting. Mrs Thomas does not have a qualification in management and care. As mentioned previously the home no longer handles any monies belonging to service users. A new and more straightforward format has been developed for care staff’s individual supervision meetings, which are to be held every two months from January 2006.
The Manor House (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 X 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 X 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X N/A 3 X X The Manor House (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES 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 Regulation Requirement Evidence must show that the service user or their representative has, wherever possible, been involved in the formulation and review of the individual’s plan of care. This requirement has been carried forward from the last inspection. Dated: 30/06/05 Timescale for action OP7 15 30/04/06 The Manor House (Residential) DS0000001006.V254675.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP25 Good Practice Recommendations All remaining radiators and pipe work in service users’ accommodation to be covered, in line with health and safety requirements. A minimum of 50 of the care staff need to have achieved NVQ level 3 in care in order for the home to meet this standard. The home’s manager should obtain a suitable qualification in management and care in order to meet this standard. 1 2 OP28 3 OP31 The Manor House (Residential) DS0000001006.V254675.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
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