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Inspection on 20/03/06 for The Manor House (Residential)

Also see our care home review for The Manor House (Residential) for more information

This inspection was carried out on 20th March 2006.

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 medication administration systems are accurately kept and the medicines are all stored correctly. The care offered to service users at The Manor House is of a high standard. Promoting the health and well-being of the people who live at the home is given the highest priority by the management and staff. The meals offered to the service users are of a good quality and people always tell me how much they enjoy their meals. The kitchen is clean and has good food hygiene routines. The home is attractive and well maintained and attention is paid to health and safety matters.

What has improved since the last inspection?

The service users` care plans are now signed either by the individual or their representative, to show that they have been discussed and agreed.More than half of the care staff have now achieved a National Vocational Qualification (NVQ) in care, either at level 2 or level 3.

What the care home could do better:

Regular individual staff supervision sessions need to be planned and notes kept of the subjects discussed.

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 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 (Residential) DS0000001006.V255614.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 (Residential) DS0000001006.V255614.R01.S.doc Version 5.1 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.V255614.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 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. The surroundings of the house and entrance are made attractive and welcoming with numerous flower filled tubs. The Manor House (Residential) DS0000001006.V255614.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 requirement and three recommendations from that inspection. The requirement and one of the recommendations have now been met. Three good practice recommendations have been made following this inspection. I would like to thank everyone who lives and works at The Manor House Residential Home for their welcome and hospitality during the inspection. What the service does well: What has improved since the last inspection? The service users care plans are now signed either by the individual or their representative, to show that they have been discussed and agreed. The Manor House (Residential) DS0000001006.V255614.R01.S.doc Version 5.1 Page 6 More than half of the care staff have now achieved a National Vocational Qualification (NVQ) in care, either at level 2 or level 3. 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 (Residential) DS0000001006.V255614.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 (Residential) DS0000001006.V255614.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 (Residential) DS0000001006.V255614.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&9 Standards 7, 8 & 10 were assessed in December 2005. Plans of care are now being signed by service users or their representatives to confirm their agreement. The medication administration system is accurate. EVIDENCE: A number of service users individual plans of care were examined and service users, or their relative’s, signatures were seen in the plans. This is important as it confirms that the service user, or someone acting for them, has agreed to their plan. The medication administration system was looked at and discussed with a senior member of staff. The records were all accurate and the quantities of medicines in stock balanced with the numbers on the records. Staff sign after each dose of medicine is offered and if it is refused, or not wanted, the reason is recorded. Any controlled drugs are also stored and recorded in accordance with the Royal Pharmaceutical Society’s guidance. The Manor House (Residential) DS0000001006.V255614.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): Standards 12, 13, 14 & 15 were assessed in December 2005. EVIDENCE: The Manor House (Residential) DS0000001006.V255614.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 (Residential) DS0000001006.V255614.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): 25 Standards 19, 25 & 26 were assessed in December 2005. The remaining radiator covers are still to be finished. EVIDENCE: Almost all of the radiators have protective covers on them. The last few in some of the communal areas of the home are still to be completed. The Manor House (Residential) DS0000001006.V255614.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): 28 Standards 27, 28, 29 & 30 were assessed in December 2005. The home now has more than 50 of its care staff with an NVQ qualification in care. EVIDENCE: Although some of the care staff do not wish to take the National Vocational Qualification (NVQ) in care, six of the eleven care staff have achieved either the level 2 or 3 qualification. The Manor House (Residential) DS0000001006.V255614.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): 31, 33, 36 & 38 Standards 31, 35 & 36 were assessed in December 2005. The home has an experienced manager, although she does not have a qualification in care and management. The home has developed an effective quality assurance system. Staff supervision needs to be held regularly and records kept. Food hygiene and other health and safety measures are kept to a good standard. 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 care home. Mrs Thomas does not have a qualification in management and care. The quality assurance systems used by The Manor House were discussed. The home has an annual development plan and the owners and management The Manor House (Residential) DS0000001006.V255614.R01.S.doc Version 5.1 Page 15 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. A new, more straightforward system of ‘one to one’ supervision with staff has been developed. I was told that some supervision sessions take place on an ‘as needed’ basis. Whether the supervision is formally arranged, or is more informal, the sessions need to be held at least every two months and notes of the discussions should be kept in the staff member’s own file. The kitchen is clean and hygienically maintained and daily records are kept of the refrigerator, deep freezer and cooked food temperatures. Regular health 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 (Residential) DS0000001006.V255614.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 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X 2 X STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 2 X 3 The Manor House (Residential) DS0000001006.V255614.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 OP25 Good Practice Recommendations All remaining radiators and pipe work in service users’ accommodation to be covered, in line with health and safety requirements. The home’s manager should obtain a suitable qualification in management and care in order to meet this standard. A programme of regular, individual staff supervision sessions should be implemented. 2. 3. OP31 OP36 The Manor House (Residential) DS0000001006.V255614.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 © 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.V255614.R01.S.doc Version 5.1 Page 19 - 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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