CARE HOMES FOR OLDER PEOPLE
Urmston Manor 61-63 Church Road Urmston Manchester M41 9EJ Lead Inspector
Val Bell Unannounced Inspection 10:00 18 January 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.V278655.R01.S.doc Version 5.1 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.V278655.R01.S.doc Version 5.1 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.V278655.R01.S.doc Version 5.1 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. 23rd September 2005 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 and is set in spacious grounds with a pleasant garden area. There is limited off-road 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.V278655.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted during daytime hours on 18th January 2006. The focus of the inspection was to assess the core Standards that were not assessed at the previous inspection and to assess progress on the requirement made previously. During the inspection records, including care plans, were examined and conversations were held with several residents, the cook, care staff and management. What the service does well: What has improved since the last inspection? What they could do better:
One requirement and two good practice recommendations were made during this inspection. The home had recently employed a cook who used to work at the home previously. Although a Criminal Record Bureau check had been obtained, new Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 Page 6 references had not been taken up. Full pre-employment checks must be undertaken for all staff recruited by the home. The staff rota did not include the management hours worked in the home. A good practice recommendation was made for these to be included and also for the rota to specify who the person in charge is on each shift. A second good practice recommendation was made. The homes quality assurance system regularly sought the views of residents and their representatives. This should be extended to include the views of visiting health and social care professionals, such as social workers and district nurses. 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.V278655.R01.S.doc Version 5.1 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.V278655.R01.S.doc Version 5.1 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 and 6 A robust system of assessment ensured that resident’s needs and preferences would be identified and recorded in the period following their admission to the home. EVIDENCE: Since the previous inspection the home had adopted the local authority’s multidisciplinary assessment model as their in-house assessment of need. This covered all the categories specified in Standard 3 and the two assessments examined had been fully completed and contained very detailed information. In conversation with the inspector residents stated that they had been involved in their assessments of need on admission. One resident recalled that a member of staff had sat down with her and her relative to find out what her likes and dislikes were. The home did not offer an intermediate care service. Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 Residents were confident that their right to privacy, dignity and respect would be maintained. EVIDENCE: A number of residents were asked if staff afforded them respect, dignity and privacy. All residents confirmed that staff treated them with respect and that their personal care needs were attended to in a dignified way in the privacy of their own bedrooms or bathrooms. Bedroom, bathroom and toilet doors were all fitted with privacy locks. One resident remarked that staff always knocked before entering their room. The inspector was also told that staff referred to them by their preferred names and it was noted that this had been recorded in the care plans. Throughout the inspection it was observed that staff spoke to residents in a respectful manner and did not discuss their personal care needs in front of other residents. Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 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): EVIDENCE: None of the Standards in this section were assessed on this occasion. However, it was noted that a music therapist was entertaining residents during the inspection. Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 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): 16 and 18 Residents were confident that their concerns would be listened to and that action would be taken to achieve a satisfactory resolution. EVIDENCE: An appropriate complaints recording system was in place at the time of inspection although no complaints had been received by the home. The complaints procedure was displayed in the homes entrance hall and was also contained in the Service User Guide and the residents contract. Residents confirmed that any concerns that they had would be listened to and they were confident that staff would take the necessary action to resolve them. At the last inspection a requirement was made for the staff to receive training in the awareness of abuse. Since the last inspection the home had joined the Trafford Training Consortium. The inspector was told that staff would now have access to training in the protection of vulnerable adults. Progress on this will be assessed at the next inspection. Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 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): None of the Standards in this section were assessed on this occasion. EVIDENCE: Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 Page 13 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, 29 and 30 A well-trained and knowledgeable staff team was caring for people living in the home. EVIDENCE: The home was appropriately staffed on the day of inspection and the rota’s provided evidence that the home regularly provided staffing in excess of the minimum required by the previous registering authority. In conversation with the inspector staff were able to demonstrate the appropriate knowledge of the needs of older people and the conditions associated with old age. The rotas did not include management hours worked in the home, although it was evident on the day of inspection that the management hours provided were sufficient. A good practice recommendation was made for management hours worked to be included on the rota. This should identify the name of the person in charge on each shift worked. A selection of personnel files was examined. A Criminal Record Bureau certificate had been obtained prior to confirming staff in post and two written references had also been obtained. However, the home had recently employed a cook who had worked at the home previously. New references had not been taken up as it was thought that the previous references would suffice. A requirement was made specifying that all new staff must have the required pre-employment checks prior to being confirmed in post. Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 Page 14 As previously mentioned in this report, the home had joined Trafford Training Consortium. This provided the staff team with a variety of training opportunities. At the time of inspection mandatory health and safety training and awareness of abuse training was being planned for staff. Three members of staff had already completed training in infection control. Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 Page 15 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): 33 and 35 The views of residents and their representatives on the quality of the service provided by the home were regularly surveyed. This demonstrated that the home was keen to undertake monitoring and review of outcomes so that improvements could be made to the service received by residents. EVIDENCE: Satisfaction surveys had been included in the Service User guide and copies were also available in the homes lounge. It was recommended that the quality assurance programme be extended to undertake surveys with health and social care professionals, such as district nurses and social workers, visiting the home. The manager stated that the home manages the personal finances for thirteen of the residents. Full accounts were held and these appeared to be accurate
Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 Page 16 and up to date. All bedrooms had been fitted with a secure facility to enable residents to lock away their money and valuables. Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 Page 17 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 Page 18 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. 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. Timescale for action 18/03/06 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. The registered person should conduct satisfaction surveys with health and social care professionals visiting the home. 2. OP33 Urmston Manor DS0000005633.V278655.R01.S.doc Version 5.1 Page 19 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.V278655.R01.S.doc Version 5.1 Page 20 - 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!
