Inspection on 16/03/07 for The Manor, Yealmpton

This inspection was carried out on 16th March 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, Yealmpton 15/12/05

The Manor, Yealmpton 09/06/05

The Manor, Yealmpton 09/11/04

The Manor, Yealmpton 02/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE The Manor Fore Street Yealmpton Plymouth Devon PL8 2JN Lead Inspector Mandy Norton Unannounced Inspection 11.10 16 & 21st March 2007 th 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 DS0000003612.V327695.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 DS0000003612.V327695.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor Address Fore Street Yealmpton Plymouth Devon PL8 2JN 01752 880510 F/P 01752 880510 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) Wells House Limited Mrs Jean Jones Care Home 22 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (7), of places Physical disability over 65 years of age (22) The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Physically Disabled (50 years and over) The Home is registered as a Care Home with Nursing for a maximum of 22 Service Users in the categories of PD(E) 22, TI(E) 22, OP 7, DE(E) 3 15th December 2005 Date of last inspection Brief Description of the Service: The Manor is situated in the village of Yealmpton within the South Hams area of Devon. The home provides nursing and/or personal care to a maximum of 22 service users over the age of 65 years of either gender with physical frailty or physical disability or illness and up to 3 service users with dementia. Accommodation is provided on 3 floors, a passenger lift provides access to the 1st floor, and a stair lift provides access to 4 bedrooms situated on the 2nd floor. Individual accommodation is currently available in 16 single rooms (five have en suite WC) and 3 double rooms. The communal areas are situated on the ground floor and comprise a lounge and conservatory. This facility offers a ‘homely’ comfortable environment. The registered provider visits the home on a regular basis and shows a commitment and interest in the service users welfare. The last CSCI inspection report is displayed in the foyer at all times for people to read. The manager is due to review the Statement of Purpose and was advised to include information about how a person who cannot visit the home or does not have access to the internet can get a copy of the inspection report. The current fees are £320 - £540 (as of 31st January 2007). The contracts examined clearly breakdown the make up of the fees charged and what is included in the fee. Contracts are issued to every Service User whether they are publicly or privately funded. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 11.10 am until 12.20 pm on the 16th March and was conducted with the nurse in charge. The inspection was concluded on the 21st March (9.50 am – 12.05 pm) with the matron as a variety of documentation needed to be examined and the matron was the only person with access to the information. A tour of the home was carried out. The report contains views from the 3 completed relatives surveys, 2 health care professionals surveys and 6 care workers surveys reflected throughout, information taken from the completed pre inspection questionnaire and discussion with staff on the day of the inspection. Service Users seen were not always able to fully express themselves or comment on the care they received. What the service does well: The Manor is homely, comfortable and welcoming. The staff are trained and competent in their jobs and there was a calm atmosphere during the inspection with staff interacting well with the Service Users. The information about the home given to prospective Service Users and or their representatives has sufficient detail to allow an informed decision to be made about moving into the home. When possible, prior to admission, the matron or one of the senior nurses visit the person in their current setting to perform a full needs assessment in addition to receiving care plans from other social and health care professionals. Once admitted to the home Service Users needs are set out in a care plan, the plans provide sufficient information for care staff to be able to meet the individuals’ health, social and psychological needs. The processes in place protect the health and welfare of the Service Users such as the complaints procedure and health and safety procedures. Regular training for the staff helps to assure the people living in the home that they are well looked after. Service Users are able to maintain contact with family and friends and exercise choice and control over their lives. Service Users receive a wholesome appealing diet that is all home cooked. Alternatives to the menu, including a vegetarian option, are always available. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 6 The home presented as clean and hygienic. 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 summary of this inspection report can be made available in other formats on request. The Manor DS0000003612.V327695.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 DS0000003612.V327695.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service or are prospective Service Users have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. The home is not registered to provide intermediate care. EVIDENCE: Pre admission documentation examined included information about Service Users assessed needs, equipment required, medications, next of kin and general information about the person. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 9 A brochure that includes the Statement of Purpose is given or sent to every person wishing to move into the home. This is available at all times in the foyer along with the most recent inspection report. The manager said that if a prospective Service User is local to the area she herself or one of the other senior trained nurses goes to visit the person in their current setting to make an assessment. The home is not registered to provide intermediate care. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 10 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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager promotes and maintains Service Users health and ensures access to health care services to meet assessed needs. The homes medication systems protect the welfare of Service Users. Service Users are treated with respect and their right to privacy is upheld. EVIDENCE: Three (3) care plans were examined; in all of those seen there were assessments which provided information about skin integrity, moving and handling, safety - including risk of falls, use of bed rails risk assessments, nutritional screening and some information about hobbies and interests. The information generates the plans of care, which provide the basis for the care to be delivered. The care plans were clear and easy to understand and had been The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 11 regularly reviewed. In some cases it was evident that the plans had been created and reviewed with input from the residents and/or their representatives. Records are maintained for all visits to the home by social or health care professionals, all residents are registered with a GP. Records in care plans detailed outpatient appointments and GP visits showing that health resources are enabled to use health resources. The medication system is well managed. The matron said stock is checked weekly and ordered monthly as often as possible. Disposal of unused/ out of date medication is safe, well recorded and removed by a licensed contractor. Staff were overheard knocking on doors prior to entering rooms of Service Users. Appropriate interactions between staff and Service Users were heard during the inspection. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 12 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. Effort is made by the home to provide an activities programme and social interaction/stimulation for Service Users. Service Users are able to maintain contact with family and friends and exercise choice and control over their lives. Service Users receive a wholesome appealing diet and are not rushed. EVIDENCE: The pre inspection questionnaire submitted prior to the inspection lists a range of activities that take place in the home and the local community including – luncheon club, bingo in local community centre, wine circle, slide shows, musical entertainment and library services. The home has holy communion services and other denominations are invited to the home if a Service User requests a visit. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 13 The menus are designed to meet the needs of the people living in the home. The menus provided with the pre inspection questionnaire are on a rolling 4 week programme and include a vegetarian option for each main meal. There are always alternatives to the menu available and snacks and drinks are available 24 hours a day. Special diets are also catered for. People can eat there meals in the conservatory where there is a small table, in their rooms or in the lounge. The chef said that he uses Safer Food Better Business documentation (this is a system of recording recently introduced that catering staff are now required to use). The environmental health officers report following his visit on 30.12.06 said that it was well implemented. The chef sources much of the food from local providers and enjoys providing fresh, home - cooked foods. He has also recently completed his NVQ 2 in food and nutrition. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 14 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 and their relatives/friends know how to make a formal complaint. People are safe living in this home. EVIDENCE: The complaint procedure was seen displayed within the home and is in the Statement of Purpose/ brochure, given to all Service Users and /or their representatives prior to admission. All 3 of the completed relatives surveys and the 2 health professionals surveys returned prior to the inspection indicated that they knew how to make a complaint if necessary. The complaints procedure is also included in the induction process for new staff. The pre inspection questionnaire states that there have no formal complaints or adult protection referrals since the last inspection. All of the nursing and care staff spoken said that that they have enough support to carry out their job. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 15 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, 22, 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. The home is safe and well maintained and clean and hygienic ensuring the Service Users live in a satisfactory environment. EVIDENCE: A tour of the home showed that Service Users rooms contain personal items including furniture, ornaments and pictures that reflect the Service Users personality and interests. The home has one lounge, one half has a TV and the other half is a quieter area. There is also a conservatory with access to a courtyard area. There is no separate dining room and although communal space is limited it meets the needs of the current Service Users. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 16 The matron pointed out the new patio area that has been built on the garden that rises from the back of the home. It has level access from the courtyard and she said that it had been well used overt he previous summer. The home appeared well equipped to meet the needs of Service Users identified with moving and handling risks and disabilities that affect their ability to bathe. Specialist mattresses and adjustable beds were seen in place for those Service Users requiring them. There is call bell system throughout the home. There were a variety of toilet facilities for use by Service Users throughout the home. There is a shaft lift to both floors. Hand washing facilities were seen throughout the home as were protective gloves and aprons. The laundry and kitchen were well equipped and large enough to manage the amount of laundry and catering required to meet the needs of the residents. The home looked well maintained during the tour of the premises, this is supported by the information supplied in the pre inspection questionnaire about dates of servicing of equipment and fire equipment tests for example. The maintenance man was seen emptying a room that was due to be re carpeted on the day of the inspection. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff with appropriate skills and knowledge to meet the needs of Service Users in this home. The homes recruitment procedures protect Service Users from being placed at risk of harm or abuse. EVIDENCE: The duty rota supplied with the pre inspection questionnaire shows that for 16 Service Users there is a trained nurse on duty 24 hours a day supported by 4 carers in the morning, and afternoon, 2 in the evening and 2 overnight. The care staff are supported by catering, domestic and maintenance staff. During a tour of the home staff were engaged with residents and there was a calm and organised atmosphere. Training records submitted with the pre inspection questionnaire prior to the inspection included continence care, fire safety, care of the dying, infection control and first aid. NVQ (national vocational qualification) training is ongoing The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 18 for a number of staff and the number of care staff already qualified to level 2 NVQ is 53 . All 3 completed relatives surveys indicated that the staff appear to have the ‘right skills and experience to look after people properly’ New members of staff are recruited following a formal application to the home, after references, Criminal record checks and an interview has taken place. The training records indicate that 5 staff have undergone induction training in the last year. Staff files examined had all of the required documentation included in them. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 19 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 & 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 managed by an experienced Registered Nurse. The Service Users benefit from the ethos and leadership within the home. The quality assurance in place ensures the Service Users are asked about what it is like living in the home. Personal money held in the home on behalf of Service Users is managed appropriately. The registered provider shows a responsible attitude toward promoting and protecting the health, safety and welfare of Service Users and staff. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager of this home is a 1st level registered general nurse who has achieved a Registered Managers Award. The manager has managed the home for many years and is well respected by the provider, local health care professionals and friends and relatives of the residents. The home has its own complaints procedure and the pre inspection questionnaire indicated there had been no formal complaints made since the last inspection. The 3 completed relatives surveys and 2 health professionals surveys indicate that they know how to make a complaint if they need to. Completed satisfaction surveys examined had mostly positive comments on them. The matron said that any issues arising from the surveys are discussed with people individually and any actions taken documented in the care plan and on the survey form The matron has an open door policy and staff spoken to said they felt able to approach her with any concerns or comments. Completed staff surveys (6) all indicated that they met regularly with the matron and one commented that ‘we have a very good and understanding matron’. The surveys indicated that although formal staff meetings do not take place regularly staff feel they are kept informed of any changes or information changes at handover and matron works with the staff so knows the level of their work. Safety notices were displayed throughout the home including action to be taken in case of fire. The completed pre inspection questionnaire indicates that all equipment is regularly maintained and tested. PAT (portable electrical appliance) testing stickers were seen on electrical equipment throughout the home. The fire and accident book were examined and both found to be completed as required. The staff accident book conforms with the latest data protection requirements. The inspector was shown he records and storage of personal money held in the home on behalf of Service Users. Best practice systems are in place for the protection of both residents and staff, all receipts are stored for auditing purposes and the money is stored securely. The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 21 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 22 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. Refer to Standard Good Practice Recommendations The Manor DS0000003612.V327695.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 DS0000003612.V327695.R01.S.doc Version 5.2 Page 24 - 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!