Inspection on 02/02/06 for The Manse

This inspection was carried out on 2nd February 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

The Manse 16/07/07

The Manse 21/01/06

The Manse 21/06/05

The Manse 16/11/04

The Manse 14/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Manse Cargoll Road St Newlyn East Newquay Cornwall TR8 5LB Lead Inspector Ian Wright Announced Inspection 2nd February 2006 09:45 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 Manse DS0000046439.V268527.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 Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Manse Address Cargoll Road St Newlyn East Newquay Cornwall TR8 5LB 01872 510844 01872 510755 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) Underhill Care Ltd Mrs Philippa Louise Jewell Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places The Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 Brief Description of the Service: The Manse provides care for up to 23 elderly residents. The home is in the village of St. Newlyn East which is situated between Truro and Newquay. The Manse has 21 bedrooms of which 19 are singles. All rooms have en-suite toilet and washbasin facilities. The home has a garden and parking for visitors. There are two shared lounges and a dining room. The home is well maintained with good quality furnishings. Respite care is offered and a room is dedicated to provide this service. Day care for up to two service users can be provided. The Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over nine and quarter hours on 2nd February 2006. The primary focus was regarding requirements from the previous inspection and other standards not inspected at that time. The inspector was able to speak to the majority of service users, and some of the staff on duty. The inspector examined the business, staff and care records, and inspected the building. What the service does well: 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 Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 6 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 Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 7 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): 1,2,5 Suitable information and opportunities are provided to enable service users to make an informed choice to move to the home for example service users can visit the home before admission is arranged. All service users obtain a Statement of Terms and Conditions of Residency so they are aware of their rights and responsibilities. EVIDENCE: Copies of the registered persons’ Statement of Purpose and Service User Guide were inspected. The registered manager said the Service User Guide was issued to service users and where appropriate their representatives. Copies of Statement of Terms and Conditions of Residency were inspected for several service users. The registered persons said a copy of this document was issued to service users or their representatives. The registered persons have developed a suitable pre admission assessment procedure. Copies of completed pre admission assessments are contained on service user files. The registered manager said service users and / or their representatives could visit the home before admission is arranged. The Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 8 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, 11 Suitable care plans and links with external professionals are maintained to ensure the needs of service users are met. Service users said staff maintain their privacy and dignity. The registered persons have a policy to provide suitable care for the dying. EVIDENCE: Each service user has a suitable care plan, and there is evidence these are reviewed regularly. Discussion with staff and service users confirmed there is appropriate links with external professionals. The registered manager said district nurses and GP’s were supportive. The inspector spoke to a district nurse who was very positive about care given by staff. Accident records were inspected, and the inspector discussed the needs of service users who had a higher than average number of falls. Precautions to prevent falls seem generally satisfactory. However moving and handling risk assessments could be more comprehensive to reflect the current needs of service users and include any preventative measures that can be implemented. Where there are concerns regarding falls-appropriate medical professionals should be consulted. The Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 9 The inspector spoke to many service users who said their rights were respected, and they were treated with dignity by staff. Clothing is labelled so service users only wear their own clothing. Service users are only addressed by their preferred form of address. This is ascertained at the pre- admission assessment. Staff were observed working with service users in an appropriate manner. The registered providers have developed a suitable policy regarding the care of service users who are dying. The Manse DS0000046439.V268527.R01.S.doc Version 5.0 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): 12 Suitable daily routines are in place so service users can receive suitable assistance tailored to their individual needs. Some activities are available for service users so there is opportunities for entertainment and stimulation. EVIDENCE: The registered manager said service users are able to get up and go to bed when they wished. Service users and the registered manager said suitable routines are in place to meet service user individual needs. For example there is flexibility when service users can have their breakfast, get up and go to bed. Some activities are arranged including occasional trips out. The Manse DS0000046439.V268527.R01.S.doc Version 5.0 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): 17, 18 Service users legal rights are protected. A suitable adult protection policy is in place and staff are made aware of this. EVIDENCE: Appropriate arrangements are in place to enable service users to vote. Suitable information is also provided regarding advocacy services e.g. in the service user guide. A suitable adult protection policy was inspected. The registered manager said staff have to read the policy within the first two weeks of employment. Formal training is planned for staff shortly. Some staff have also attended external training regarding abuse and adult protection. The Manse DS0000046439.V268527.R01.S.doc Version 5.0 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): 19-26, The registered provider provides suitable facilities to meet the needs of service users. The home is well maintained, clean, comfortable and homely. EVIDENCE: The inspector inspected the premises. The building is suitable to meet the needs of service users. The home is generally well maintained, clean, is homely and comfortable. All bedrooms are en-suite, and service users are able to bring in their own possessions and furniture. Bedroom doors all have locks and service users are provided with a key if they have the capacity to use this. The majority of windows have been replaced since the last inspection. One bedroom had a smell of urine, and there was a stain on the carpet. The registered manager said staff were aware of the issue, and the carpet was regularly cleaned. She said she would arrange for the carpet to be cleaned as soon as possible. The Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 13 One lady said she would like a hook on the back of her bathroom door. The registered manager said she would arrange this. Shared facilities e.g. lounges are comfortable. Service users can smoke in the conservatory. Bathrooms and washing facilities are satisfactory. There is a walk in shower facility, and assisted bathing facilities. Other suitable adaptations and equipment include an integrated call system, a stair lift and hoists. Heating and lighting are suitable. The Manse DS0000046439.V268527.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 Suitable staffing levels are maintained so service users can be assured their needs can be met. Improvement is required regarding information obtained for staff pre-employment checks. The registered providers have a suitable training policy. However, there are some gaps in training received by staff as required by regulation. EVIDENCE: The registered manager stated there are three staff on duty from 7:30 to 22:00 (except for the period 15:00 to 16:00 when two staff are on duty), with one sleep in and one waking night member of staff. This was appropriately documented on the rota. Domestic staff and a cook are also employed. The Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 15 Information regarding pre employment checks requires some improvement. For example all staff must have two references. Most staff have a Criminal Records Bureau check (CRB) and Protection of Vulnerable Adults Check (POVA) (where applicable). Where staff are still awaiting a CRB /POVA check, the registered manager said they are supervised in line with current government guidance. The registered persons outlined a suitable approach for enabling staff to obtain National Vocational Qualifications (NVQ) in care. Certificates are on file for staff that have obtained either an NVQ 2 or 3. There is evidence that most staff have received a formal induction. However evidence of structured induction was not available for two overseas workers, one who had recently started, and one who had been in post for several months. Evidence of training delivered to staff has improved although there are still some gaps in training required by regulation such as first aid, food handling and infection control training. Staff are required to have this training within six months of employment and updated as required. Evidence of fire training should be improved. The fire officer should be consulted regarding what training is required by regulation for all care staff. The registered manager said staff are currently completing distance learning training regarding dementia awareness. The Manse DS0000046439.V268527.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): 32, 33, 36, 37, 38 The registered persons outlined a suitable ethos and management approach, so the home is led in the interests of service users. Policies, procedures and records are suitable, and give staff appropriate guidance to care for service users. Health and safety precautions require some improvement for example regarding training, and portable electrical appliance testing, so staff and service users can be assured the home is safe. EVIDENCE: The registered persons appear to be approachable, and demonstrate a suitable attitude to ensure staff work in a caring manner. The inspector spoke to several staff who were happy with the care provided, and the support and training they received. Staff meetings were last held in January 2006 and August 2005. The Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 17 Service users have completed quality assurance questionnaires, and these gave a generally positive view of services provided. Residents meetings take place and are documented. Records examined regarding the management of the home, and service users care are appropriate. The registered persons provide suitable supervision system is also in operation, appraisal system is also in operation. It comments were recorded, although the feedback is always given. day-to-day supervision. A one to one and supervision is documented. An would be beneficial if appraiser’s registered manager said verbal Health and safety precautions are generally satisfactory for example in regard to servicing of moving and handling equipment, fire, and gas equipment. Suitable health and safety risk assessments are completed. However portable electrical appliances need to be retested. The registered persons must also complete a risk assessment regarding the prevention of Legionella, and take necessary precautions regarding this. The Health and Safety Executive publish a leaflet regarding this issue, and the Environmental Health Department may be able to give some advice. The Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 18 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X 3 3 2 The Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 19 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 OP8OP7 Regulation Requirement Timescale for action 01/06/06 12, 13, 15 The registered manager must: • Review service user moving and handling risk assessments. Where necessary these should be more comprehensive to reflect the current needs of service users. Any realistic preventative measures to reduce falls should be recorded and implemented. • Where there are concerns regarding falls-appropriate medical professionals should be consulted. 19 The registered persons must obtain two references for new staff employed. Where verbal references are initially obtained, these should be recorded and later confirmed in writing. Staff must receive training appropriate to the work they perform. This must include training required by regulation for example first aid, infection control, food handling, manual handling. DS0000046439.V268527.R01.S.doc 2 OP29 01/03/06 3 OP38OP30 13, 18 01/06/06 The Manse Version 5.0 Page 20 4 5 OP30 OP38 18 13, 23 (Previous deadline of 1/10/05 not met 2nd Notification) All staff must receive an induction and there must be documentary evidence of this. The registered persons must: • Test portable electrical appliances annually and provide evidence of testing. • Complete a risk assessment regarding the prevention of Legionella, and take necessary precautions regarding this. 01/03/06 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP38OP30 Good Practice Recommendations The registered persons should: • Improve recording of fire training for individual staff. • Make available an outline of the fire training session if management gives this. • Consult with the fire officer regarding what training is required by regulation for all care staff. The Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Manse DS0000046439.V268527.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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