Inspection on 21/06/05 for The Manse

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 02/02/06

The Manse 21/01/06

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 21 June 2005 9:30 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 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 D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 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 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 D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16.11.04 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 D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over ten and three-quarter hours. The inspection was carried out on an announced basis. 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 medication system, 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: The inspector raised concerns regarding how allegations of poor practice and abuse have been dealt with. These have been referred to Cornwall social services and also the registered provider to investigate. There must be a choice of hot meal available, and menus for service users with special diets must be improved. The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 6 Although the building is generally well maintained, there are some problems with some service user’s windows and these must be addressed. There should also be locks on bedroom doors, and service users given a key if they have capacity to use it. Procedures and documentation for staff employed from overseas must be improved. For example a Criminal Records Bureau check must be completed for these staff when they are employed. Procedures and documentation regarding induction and training also needs improvement. Some minor improvements are required regarding documentation of health and safety precautions e.g. risk assessments must be reviewed more regularly. For example any risks (such as trips and falls) must be highlighted and steps are taken to minimise these risks. 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 D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 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 standard(s) 3-4 The registered persons have a suitable procedure to assess service users before admission so service users know their needs will be met when they are resident. Satisfactory links with external professionals have been developed. EVIDENCE: Suitable pre admission assessments were available. Records and discussion with staff and service users confirm the registered persons have suitable links with external professionals such as district nurses, GP’s. The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 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 standard(s) 7-10 Suitable care plans and links with external professionals are maintained to ensure the needs of service users are maintained. An appropriate medication system is maintained so service users can feel assured their medication is managed appropriately. Service users said generally staff maintain their privacy and dignity; although significant concerns regarding two members of staff were raised by service users. 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 assessed the home’s medication system. This appeared to be well managed. There was suitable documentation for example regarding the administration and disposal of medication. Service users said the majority of staff maintained service users privacy and dignity. However service users raised concerns regarding two members of The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 10 staff. These matters have been referred to the registered provider to conduct an internal investigation. The matters have also been referred to social services for investigation under their adult protection procedure. A requirement has been made elsewhere in the report for a suitable locking system to be fitted to service user bedroom doors. The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 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 standard(s) 12-15 Routines are flexible so life in the home can meet individual service users expectations and preferences. Arrangements are in place regarding service users finances so service users are helped to exercise choice and control over their lives. Meals provided are generally to a good standard. However some improvement is required so an alternative is more widely publicised. The registered manager must provide an improved choice for service users who have individual special diets. EVIDENCE: 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. Service users said they can have visitors at any time. The registered manager said some monies are kept on behalf of service users in the safe. In the absence of any next of kin / legal representative, the manager signs for one service user’s money at the post office. Appropriate records are maintained for all transactions. The registered manager said The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 12 service users’ legal representatives or relatives maintain other service users finances. The inspector shared a meal with service users, which was to a good standard. The registered manager said staff catered for service users with special diets e.g. diabetics. Service users were generally positive about meals provided although a minority of service users said there should be an alternative hot meal if they did not like what was offered. Similarly a service user who had a stomach problem did not feel her special dietary needs were being recognised. The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 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 standard(s) 16, 18 Suitable adult protection and complaints policies are in place, and made available to staff and service users. The Commission for Social Care Inspection is concerned about implementation of the adult protection policy, as allegations, which the registered persons were aware of, were not acted upon e.g. referred to social services. This could have put service users at considerable risk. EVIDENCE: Suitable documentation for complaints and adult protection procedures are in place. One complaint was received by the registered provider, which was investigated. The Commission for Social Care Inspection received another complaint regarding manual handling equipment- this has been appropriately resolved and an additional hoist purchased. A minority of service users expressed concern to the inspector regarding the attitude and actions of two members of staff. These concerns have been referred to the registered provider and Cornwall social services for investigation. The Commission for Social Care Inspection is disappointed that although the registered persons appeared to be aware of some of the allegations no action had been taken to investigate the situation. The registered persons appeared to be under the impression that such allegations must be made in writing, and felt constrained by legal advice offered. The registered persons are advised to re-read its adult protection policy, ‘No Secrets’ (Department of Health 2000) and the local authority adult protection policy. The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 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 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, was clean on the day of the inspection, and is homely and comfortable. All bedrooms are en-suite, and service users are able to bring in their own possessions and furniture. Bedroom doors do not have locks and these should be provided if service users want them. All service users must subsequently be provided with a key to their bedroom door unless there are health and safety reasons, which a risk assessment concludes, could result in a significant risk of harm to the service user. Two service users requested the glass in their bedroom windows be replaced as this had become impossible to see through. The wooden frame in one bedroom window was rotten and must be replaced. The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 15 The registered manager said the windows on one side of the home (where the reported problems are situated) will be replaced this summer. 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. There are appropriate facilities to ensure good hygiene and the control of infection. The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29,30 Suitable staffing levels are provided to meet the needs of service users. Recruitment procedures are generally satisfactory although some improvement is required for overseas staff. Induction (for overseas staff) and training must be improved, and there must be appropriate evidence staff have received training (e.g. copies of certificates.) EVIDENCE: The registered manager stated there were three staff on duty from 7:30 to 22:00, with one sleep in and one waking night member of staff. This was appropriately documented on the rota. The home’s staff recruitment procedure appears generally appropriate, and satisfactory personnel information was available on staff files. The registered manager said staff have received an appropriate staff induction, and training required by regulation. The homes accounts document over £3000 was spent on training in the last financial year. The registered manager has stated the vast majority of staff have National Vocational Qualification’s in care (e.g. 3 staff with NVQ 3, 7 with NVQ 2, and three who are currently doing NVQ 2.) However apart from the training records of the registered manager, other staff records of induction and training were patchy or non-existent. Staff must The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 17 receive training as required by regulation, and the registered persons must be able to provide suitable evidence of this (i.e. copies of certificates). The personnel and training records of two overseas workers require improvement: • A Criminal Records Bureau / Protection of Vulnerable Adults check must be obtained when overseas workers commence employment. • There must be evidence of suitable induction and training as required by regulation. • The registered persons are advised a telephone interview is completed before an employment offer is made. It is also advised the applicants complete an application form in English. The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 34-38 The registered persons have suitable skills, experience and knowledge to manage the home. Suitable records are maintained regarding service users, and the running of the business e.g. in regard to financial viability. Arrangements for the management of staff are generally satisfactory although the inspector is very concerned how the registered persons have dealt with cases of suspected abuse picked up on the inspection. Health and safety precautions are generally satisfactory although some improvements regarding documentation are required. EVIDENCE: The registered manager has completed the registered manager’s award, and is currently completing NVQ 4 in care. Suitable accounts are maintained in the home, and audited accounts confirm the home is financially viable. Suitable records are maintained for service The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 19 user’s monies. For a minority of service users, staff act as a signatory for their pensions. Such a measure should be avoided but in the cases concerned the registered manager stated there was no immediate next of kin. There was evidence staff receive appropriate day to day, and formal supervision. The inspector however is very concerned about the adequacy of how allegations of bad practice and abuse have been handled as documented under National Minimum Standard 18. Such matters must be discussed, and appropriate action taken e.g. through the supervision process. Suitable records were observed regarding the care of service users, and the running of the business. Documentation of health and safety precautions is generally satisfactory. For example fire equipment, moving and handling, gas and electrical equipment is tested appropriately. The health and safety risk assessments were last reviewed in 2001, these are in need of review and should be reviewed at least annually. Health and safety training must be evidenced as outlined under National Minimum Standard 30. The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 3 x x 3 3 2 3 2 The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 21 YES Are there any outstanding requirements from the last inspection? 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 29, 37 Timescale for action 17, 19 Records must be kept in line with 1.10.05 the requirements in Schedule 4 of the Care Homes Regulations 2002. (2nd Notification) 1.7.05 10, 12, The registered provider must 13, 19, 37 investigate allegations of abuse under its adult protection procedure. The matter has also been referred to Cornwall social services and the registered provider must co-operate with their investigation. The Commission for Social Care Inspection must be kept informed of progress with these investigations. 12,13, 16 An alternative hot meal must be 31.7.05 provided and widely publicised (e.g. this could be to order if notice is given). Meals provided must meet the needs of service users who have a special diet. 12, 16, 23 Bedroom doors must have a lock 1.10.05 fitted if service users want them. *Where service users do not want a lock on their bedroom door this should be documented and a signature from the service user obtained to confirm they have been consulted. *All service users must D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 22 Regulation Requirement 2. 10, 18, 36 3. 15 4. 10, 26 The Manse 5. 19, 24 6. 30, 38 7. 29 8. 30, 38 subsequently be provided with a key to their bedroom door unless there are health and safety reasons, which a risk assessment concludes could result in a significant risk of harm to the service user 16, 23 The registered provider must: * Replace the glass in the bedroom windows of two service users bedrooms. * Repair one service users bedroom window where the frame is rotten. *Confirm to the Commission in this reports action plan if and when any / all windows in the home will be replaced. 12,13, 18 The registered persons must: *provide appropriate training as required by regulation (e.g.50 of staff must have an NVQ 2 in care by 1.1.06, fire training, infection control, first aid (as applicable), moving and handling, food handling (as applicable). *be able to evidence training required by regulation has been delivered (e.g. a copy of certificates for each member of staff is available.) *provide evidence that suitable induction is completed for all staff. 19 A Criminal Records Bureau / Protection of Vulnerable Adults check must be obtained for overseas workers when they commence employment. 12, 13, 32 Documentation must be improved regarding: *Health and safety risk assessments. These should be reviewed at least annually. *Health and safety training. 1.10.05 1.10.05 31.7.05 1.10.05 9. The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 23 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 18 Good Practice Recommendations The registered persons are advised to re-read the homes adult protection policy, ‘No Secrets’ (Department of Health 2000) and the local authority adult protection policy. The registered persons are advised a telephone interview is completed for overseas staff before an employment offer is made. It is also advised the applicants complete an application form in English. 2. 29 3. The Manse D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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 D52-D04 S46439 The Manse V222180 210605 Stage 4.doc Version 1.40 Page 25 - 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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