Inspection on 15/11/06 for Urmston Manor

This inspection was carried out on 15th November 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

Urmston Manor 18/01/06

Urmston Manor 23/09/05

Urmston Manor 26/01/05

Urmston Manor 05/10/04

Urmston Manor 26/03/04

Urmston Manor 15/12/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Urmston Manor 61-63 Church Road Urmston Manchester M41 9EJ Lead Inspector Nick Allen Unannounced Inspection 10:00 15 November 2006 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 Urmston Manor DS0000005633.V306187.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. Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Urmston Manor Address 61-63 Church Road Urmston Manchester M41 9EJ 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) 0161 747 6510 0161 755 3245 Mrs Jacqueline Entwistle Mrs Marjorie Coleman Mrs Jacqueline Entwistle Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users will fall within the category of old age, but may in addition have a physical disability. 18th January 2006 Date of last inspection Brief Description of the Service: Urmston Manor is a care home registered to provide accommodation and personal care to twenty-four older people in twenty single and two double bedrooms. The home is located in a residential area of Urmston, Manchester. The home is set in spacious grounds with a pleasant garden area. There is limited parking at the rear of the building and space to park on the road at the side of the home. The home is on a main road with good access to public transport facilities into Manchester and surrounding areas. A selection of shops and Urmston market are close by. The home provides personal care within a broadly domestic setting to meet the needs of older people who do not have high dependency needs. Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of five hours. The home was not aware that an inspection was to take place. This was a key inspection, which means that all the key care standards identified by the Commission for Social Care Inspection were inspected. The inspection process included the examination of three service-user assessments and care plans, examination of other documents concerned with the care of service users and the running of the home, including the staff rota, staff files, medication records, the accident book together with other records and reports. An observation of the interactions between staff and service users was also undertaken. Over the course of the inspection a four residents and three members of staff spoke to the inspector. A tour of the communal, public and private areas of the building was also undertaken. What the service does well: What has improved since the last inspection? There had been some redecoration of parts of the home. This was in keeping with the programme for renewal and refurbishment. Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 6 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. Urmston Manor DS0000005633.V306187.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 Urmston Manor DS0000005633.V306187.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 Quality in this outcome area was adequate. This judgement has been made using the available evidence including a site visit to the home. The home provides adequate information to enable potential residents to make an informed choice about moving into the home. The home ensures that residents have their health needs met by completing a comprehensive need assessment prior to, or soon after, becoming resident in the home. EVIDENCE: The home’s service user guide contained information about staff qualifications and experience, the philosophy of care provision, a brief description of the home and its facilities, visiting arrangements and a copy of the homes complaints procedure. Residents’ files were examined. Of the files examined all contained signed contracts. During discussion the manager also stated that residents and their representatives were encouraged to visit the home prior to admission. Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 9 Detailed assessments were seen in all care files and these included information about the psychological well-being, food preferences, health and social needs and expectations of the service users. Urmston Manor DS0000005633.V306187.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All key standards Quality in this outcome area was good. This judgement has been made using the available evidence including a site visit to the home. The health care needs of service users are well-documented and known to staff, which ensures that such needs are met. Medication was stored in accordance with the homes medication policies and procedures. Privacy and dignity of residents was maintained at all times. EVIDENCE: Care plans were examined and instructions about meeting health needs were clearly identified. Records and daily reports for residents confirmed that all routine and specialist health care was provided. Results and prescriptions confirmed that health care checks including opticians, dentist and podiatry as well as out patient appointments, nursing care and other specialist input was arranged as necessary. Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 11 Three residents were interviewed and all were satisfied with the standard of health care provided in the home. A fourth person said that they liked the staff and the manager however they said that they would never complain to anyone. The staff interaction was observed and monitored, it was noted that for the most part staff supported residents in accordance with the instructions written in the care plans. Records showed that medication policies were followed and staff sought the consent of residents before giving medication, it was noted that appropriate support was offered to ensure medication was successfully administered. During the time spent at the home it was noted that staff offered residents the opportunity to maintain their dignity whilst personal tasks were undertaken. It was also noted that diversity of need was promoted. Urmston Manor DS0000005633.V306187.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All key standards Quality in this outcome area was good. This judgement has been made using the available evidence including a site visit to the home. The range of activities in the home provided individuals with choices and opportunities to take part in a wide range of appropriate activities including ones external to the home. Visiting time in the home was flexible and in line with the needs of service users ensuring that they maintain good contact with family friends. The nutritional value of meals provided was in keeping with current guidelines, including choices offered to those on special diets. EVIDENCE: The activities calendar was examined and activities included a variety of activities. It was also observed in the daily reports that staff assessed whether individual service users participated in or enjoyed the activities offered. It was also recorded in daily reports when activities had not taken place. Of those residents spoken to all said that they were happy with the activities offered. One said there was “plenty” another said that they could choose not to do things if they wanted. Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 13 Residents spoken to confirmed that were consulted about the way the home operated and about changes being made. One said, “It’s just like living in one big family and everyone choosing what they want… you have to compromise sometimes” Of those people observed some included the residents whose care plans were examined. From these observations it was possible to conclude that service users relate well to each other and staff, comments from service users included “A lot of them like a laugh” and “Lovely staff.” On the day of inspection the cook was preparing the meals with assistance from other staff. It was noted that service users made favourable comments about the food and particularly enjoyed the pudding. Menus were examined and demonstrated a variety of meals including stews meat pies, with appropriate alternatives. The store cupboards were examined and found to be adequately stocked. Urmston Manor DS0000005633.V306187.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All Key standards Quality in this outcome area is good. This judgement has been made using the available evidence including a site visit to the home. The homes complaints procedure was robust, clearly written and staff and service users understand who they can go to and that they are entitled to voice any complaints and be listened to if they have any concerns. EVIDENCE: There was a clear complaints procedure for the residents and their relatives; a copy of this procedure was given to all prospective residents and their relatives. Residents told the inspector that they had no complaints at all. There have been no recorded complaints at the home or to the Commission for Social Care Inspection. Urmston Manor DS0000005633.V306187.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All key standards Quality in this outcome area is good. This judgement has been made using the available evidence including a site visit to the home. A safe and comfortable environment was provided for the residents. Bedrooms were furnished and decorated to suit the individuals’ tastes and preferences, meaning people are living in homely surroundings. EVIDENCE: The inspector visited residents’ bedrooms and noted that each room was personalised and comfortable. There was a lounge and dining area that were comfortable and homely. There was an ongoing refurbishment programme for the home. Three of the bedrooms had en-suite facilities and there were adequate toilet and bathing facilities in place throughout the home. Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 16 The inspector noted that there were aids and adaptations such as grab rails in toilets and special lifting and bathing hoists for the residents who need help with their mobility. There were also assisted baths for residents that could not get in and out of the bath without help. The laundry room was in the cellar of the home and was kept very clean and tidy; the washing machines had programmes for disinfecting and sluicing laundry. The inspector was satisfied that the laundry systems were hygienic, however there were no hand-washing facilities in the laundry room. Currently the staff use the sluice. However if there were a basin for the staff to wash their hands, it may improve the hygiene levels for the staff. Urmston Manor DS0000005633.V306187.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All key standards Quality in this outcome area is adequate. This judgement has been made using the available evidence including a site visit to the home. The levels of staff and the mix of skills ensure that the residents are properly cared for. A training calendar had been developed and staff training ensured that residents received a good quality of care. The home’s recruitment practice is adequate ensuring that for the most part staff are suitably vetted and affords appropriate protection to service users. However there were concerns about the Criminal Record Bureau checks not being thorough. EVIDENCE: The inspector noted from the duty rota that the staffing levels at the home are very good indeed. Discussions with the staff confirmed there was a good mix of skills and experience amongst the carers and trained nurses. The residents told the inspector that they were very well looked after and that they did not have to wait for attention when they needed it. Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 18 At the time of the inspection a number of staff files were examined. One was for a member of staff who had recently been recruited to the home. It was noted that the Responsible Individual had not undertaken the staff members CRB. They had left this to the member of staff to complete themselves. This is not in line with the recruitment process. Urmston Manor DS0000005633.V306187.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All Key standards Quality in this outcome area is good. This judgement has been made using the available evidence including a site visit to the home. The home makes sure that the best interests of the residents are protected in that all Health & Safety procedures are in place, and residents are safe. EVIDENCE: The Responsible Individual has had suitable experience in the management of care services for older people, they had undertaken relevant professional training. Policies and procedures had been kept under review and required actions from previous inspections had been progressed within timescales to ensure continuous service improvement. Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 20 Supervision and appraisal processes had been established. These processes were thorough and supported general supervision and guidance that were provided for staff on a routine daily basis. Records were maintained in good order and stored in accordance with data protection requirements. There was an understanding of the importance of confidentiality and data protection requirements. Training in safe working practices was provided for staff members. Refresher training in these topics plus moving and handling training for staff was available. The Responsible Individual works full time at the home and is aware of all issues. There was evidence that she kept up to date with events by reading all files daily. Health and safety policies and procedures were in place with safety notices posted appropriately throughout the building. A fire risk assessment and fire records were provided for inspection. Gas, central heating, electrical and water temperature checks had been carried out. The measures taken had improved the safety of the environment for the benefit of residents. The Responsible Individual completed all appropriate notifications. Urmston Manor DS0000005633.V306187.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 X X 3 X X X 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 22 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 OP29 Regulation 19 Requirement The registered person must ensure that the required preemployment checks are undertaken with all staff recruited to work in the home. Previous time scale of 18/03/06 not met. Timescale for action 31/12/06 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 OP27 Good Practice Recommendations The registered person should ensure that the management hours worked at the home are included on the staff rota. This should identify the person who is in charge on each shift. Urmston Manor DS0000005633.V306187.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Urmston Manor DS0000005633.V306187.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. 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