Inspection on 01/08/06 for The Manor Residential Home

This inspection was carried out on 1st August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Manor Residential Home 28 Church Street Arnold Nottingham NG5 8FB Lead Inspector Karmon Hawley Unannounced Inspection 1st August 2006 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 Residential Home DS0000065712.V306442.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 Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor Residential Home Address 28 Church Street Arnold Nottingham NG5 8FB 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) 0115 9535577 0115 9535588 The Manor Residential Home (Arnold) Limited Mrs Lynne Joy Crampton Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category OP Date of last inspection 05/01/06 Brief Description of the Service: The Manor House is an extended and converted building catering for the needs of older people. It is within walking distance of the town centre. The home has twenty-five single rooms seven of which are en-suites. There is a chair lift for access to the first floor for people with a physical disability. There is a lounge and a large dining room. A large conservatory overlooks the front garden and is in constant use throughout the year. This area is also used for service users and their families to meet in private if they want to. There are facilities for assisted bathing and toileting. All the rooms overlook the garden and are light, bright and fresh smelling. All areas of the home are maintained, and furnished to a very high standard. The current weekly fees are as follows: £335, £360, £372, prices are dependant upon the room size and facilities, this is discussed at the point of enquiry. The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and thus the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. The unannounced site visit took place in four hours and was performed by one inspector. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of four randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Six service users were spoken with, so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The manager assisted in the inspection process and two members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job role. The provider and manager are both fully committed to ensuring service users receive a high quality service and held discussions with the inspector in respect of their visions to continue to develop the home and provide an excellent service. What the service does well: A kind and caring ethos was prevalent throughout the home and staff were observed to interact in a meaningful manner with service users. Service users spoken with were extremely happy with care received and life within the home. One service user spoken with stated that ‘this is the best home’ and another stated that ‘staff are kind and respectful at all times.’ Staff spoken with were knowledgeable and were able to discuss the issues in respect of ensuring equality and diversity is enhanced in the ethos of the home. A high number of staff have attained training in the National Vocational Qualification. The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 6 The home is extremely well maintained, clean, pleasant and hygienic. Service users have been giving the opportunity to make choices in the re decoration of their rooms. What has improved since the last inspection? 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 Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 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 Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 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 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users may be assured their needs will be assessed and met prior to moving into the home. EVIDENCE: Service users are visited in the community prior to entering the home and a preadmission assessment is undertaken. There was evidence of this taking place in service users files examined and the assessment covered the requirements of the standard. Service users and relatives may also visit the home prior to admission. The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 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): 7,8,9,10 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users health, personal and social care needs are set out in an individual plan of care. Further development of risk management plans is required to ensure service users are fully protected. Service users health care needs are fully met. Service users are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Four case files were examined and demonstrated that various assessments take place with regards to the daily activities of living, manual handling, falls, pressure area care and nutrition. Information from these forms the basis of the plan of care. Plans of care in place were personalised and outlined care required. It was evident where changes in service users conditions had occurred and relevant assessments were available to underpin this. Progress notes are maintained and demonstrate care received and all significant events The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 10 are noted. Risk assessments and management plans were in place, however in regards to falls sufficient information with regards to the management of this was not available. Also where bedrails are in use a risk assessment in respect of the risk of entrapment was not available, however on speaking with staff they were able to discuss these issues. Where a service user had diabetes mellitus a risk assessment was not in place should any changes in their condition occur, however the manager was able to discuss how this would be dealt with. Service users spoken with stated their needs are met, staff were able to discuss service users needs, care required and the core values and principles. There was evidence within service users plans of care to demonstrate that the multidisciplinary team and specialist services are accessed as required. Relevant equipment to meet service users needs was available within the home. Medication and medication procedures were examined and were satisfactory. Appropriate policies and procedures were in place. Staff are instructed on maintaining service users privacy and dignity, service users spoken with stated that staff were always kind and considerate and privacy was maintained. The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 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 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users are enabled to find the lifestyle experienced in the home matches their expectations and preferences and satisfies their need. Service users are enabled to maintain contact with relevant others. Service users are helped to exercise choice and control over their lives and staff recognise and practice equality and diversity in the home. Service users receive a wholesome and appealing diet in pleasing surroundings. EVIDENCE: Staff and service users spoken with stated that the routine of the home was flexible and service users may choose how they spend the day. Both substantiated that they may choose when they rise and retire. There is an activities coordinator employed who works two days a week. Various activities are on offer and service users also enjoy trips outside the home. Service users spoken with stated that activities were enjoyable and several discussed the recent boat trip they had taken. One service user spoken with stated that they would like more activities, this was discussed with the manager who will follow this up, whereas the remaining five were satisfied with activities on offer. The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 12 A monthly church service is held in the home should service users wish to join in and the manager ensures service users have to opportunity to attend church for special occasions should they wish. There are no restrictions on visiting and service users substantiated this and stated that visitors are always made welcome. The main door is kept locked, however regular visitors are informed of the access code. Visitors may be received in private and one service user spoken with discussed this with the inspector. Staff were able to discuss how equality and diversity is recognised and enhanced within the home, this was also reflected in plans of care. Service users spoken with stated that staff were respectful at all times and treated them as individuals. Service users have access to a telephone should it be required and some service users have their own personal line. All mail is received unopened. Service users if able remain responsible for their personal finances. Advocates would be accessed if required. Service users are able to bring in personal possessions if they wish; one service user spoken with substantiated this. Records observed in the kitchen demonstrated that service users receive a wholesome and appealing diet. Choices and alternatives are offered; service users spoken with substantiated this. Specialist diets are also catered for and there was evidence of this within service users plans of care. The kitchen was clean and tidy on the day of inspection and all relevant records were maintained as required. The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 13 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 quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users and relevant others may be confident that their complaints will be listened to taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Appropriate policies and procedures are in place with regards to the handling of complaints. There have been no complaints received since the previous inspection. Service users spoken with expressed no concerns. Staff spoken with were able to discuss how they would deal with a complaint should it be received. Appropriate policies and procedures are in place in respect of adult protection. All staff have satisfactory criminal record bureau checks in place and the majority of staff have undertaken training in this area. Staff spoken with were able to discuss the relevant issues in regards to adult protection. The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 14 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 quality rating for this outcome area is excellent this judgement was made using evidence available including a visit to the service. Service users live in a safe and excellently maintained environment. The home is extremely clean, pleasant and hygienic. EVIDENCE: An ongoing maintenance plan continues and there was evidence available to substantiate this. Several service users rooms have been redecorated to a high standard and one service user spoken with stated that they had been able to have a choice in the way this was done. CCTV is operational within the premises of the home, there is relevant signage displayed to inform people of this. The previous inspections undertaken by the environmental health officer and fire officer were both satisfactory and no requirements were set following these visit. The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 15 The home was extremely clean pleasant and hygienic and there are ample domestic staff employed to maintain this. Two service users spoken with stated that the home was always clean and tidy. Relevant equipment and hand washing facilities were available throughout the building. The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 16 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 quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. The numbers and skill mix of staff meets service users needs. Service users are in safe hands. Service users are supported and protected by the homes recruitment policies and procedures. Staff are trained and competent to do their jobs. EVIDENCE: The duty rotas were observed and demonstrated that ample staff are employed to meet the needs of service users. Five service users spoken with stated that staff were plentiful and available to meet their needs. Staff spoken with stated that sufficient staff were available. Ten members of staff have attained the National Vocational Qualification level two; six members of staff have attained level three. A further 4 staff are due to commence level two and 2 to commence level three. All new staff undertake a recognised induction programme on commencing employment. Four staff files were observed and contained all required documentation. Staff training files demonstrated that staff are working towards completing all mandatory training. Staff spoken with stated that training was at a good standard and they were offered sufficient training to meet their needs. Staff The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 17 spoken with were able to demonstrate knowledge through discussions with the inspector. The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 18 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): 31,33,35,28 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. 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 her responsibilities fully. The home is run in the best interests of service users. Service users financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager has now been employed at the home for ten years, during which she has continued to develop her skills and knowledge. She ensures she remains up to date with mandatory training and has completed the registered managers award. Service users spoken with stated that the manager was The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 19 always approachable and kind and caring. Staff spoken with also spoke highly of the manager and stated that she was approachable. Annual questionnaires are given to service users in addition to a small questionnaire given to district nurse and general practitioners. Three service users spoken with stated that they had just received a questionnaire to complete. The manager stated that once these are completed they would be examined and feedback would be offered. If there were any concerns noted these would be dealt with on an individual basis. Policies and procedures are reviewed on an annual basis. The provider also draws up an annual development plan along with the annual business plan. Service users are also given the opportunity to express any views at service users meetings, which are held on a monthly basis. Service users may keep personal allowances in safe keeping at the home, four accounts were checked, three were correct whereas the other had more money in the wallet than was in the account book. The manager discussed this issue and how it may of occurred, the manager and provider then discussed a change in arrangement, which would remedy this and prevent reoccurrence. Receipts are maintained for all transaction, which are also signed for by a staff member. Relevant policies and procedures are in place with regards to personal allowances and the acceptance of gifts and wills. All required maintenance records, tests and certificates were available for inspection. The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 20 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 X 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 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 21 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 OP7 Regulation 13(4,c) Requirement To continue to develop risk management plans to ensure service users are fully protected from highlighted risks. Timescale for action 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Manor Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Residential Home DS0000065712.V306442.R01.S.doc Version 5.2 Page 23 - 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!