Inspection on 03/07/07 for Walkden Manor

This inspection was carried out on 3rd July 2007.

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

Walkden Manor 18/02/09

Walkden Manor 15/01/08

Walkden Manor 23/10/06

Walkden Manor 26/02/06

Walkden Manor 12/05/05

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 Walkden Manor 41 Manchester Road Walkden Worsley Gtr Manchester M28 3WS Lead Inspector Rukhsana Yates Unannounced Inspection 10:00 3 & 5th July 2007 rd 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 Walkden Manor DS0000062619.V335772.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. Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Walkden Manor Address 41 Manchester Road Walkden Worsley Gtr Manchester M28 3WS 0161 790 9951 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) Walkden Manor Care Home Ltd Mrs Sonia Jane Duffy Care Home 29 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (29) of places Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 29 older people (OP) requiring personal care only may be accommodated. Within the overall numbers two (2) service users who are currently accommodated are under the age of 65 and also have dementia (DE). If these service users leave the category will revert to OP. When either of the service users reach the age of 65 the category will be OP (DE). 23.10.06 Date of last inspection Brief Description of the Service: Walkden Manor is a residential care home situated in the centre of Walkden, Salford. The home provides personal care and support to older people. Bedrooms are situated on the ground and first floor of the accommodation with the laundry, office and main kitchen located in the basement. There is a large, flagged patio area to the rear of the home and a small car park situated at the side of the building. The weekly fees rang from £317.92 to £372.42 per week. Additional charges are made for hairdressing and for trips. Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In order to find out about the experiences of people living at Walkden Manor, a visit was carried out without letting anyone know beforehand, with a total of 11 hours spent at the home. The time was spent talking with people about their daily life in the home, watching the ways in which staff supported them, talking with the manager and staff, and looking at paperwork relating to care and safety. The findings of the inspection take account of comments made by people living and working there, and also written information received from the manager and from those living at Walkden Manor. The service was inspected against key standards for homes for older people to see how well it was meeting a range of needs. These standards cover moving in, the care provided, daily routines and lifestyle, complaints, safety, comfort and cleanliness, how staff are employed and trained, and how the service is managed and developed. The term preferred by the people consulted during the visit was “residents”. This term is, therefore, used throughout the report when referring to those living at the home. What the service does well: What has improved since the last inspection? Residents felt that the home is brighter because some areas of the home have been redecorated since the last inspection. The care plans have more information about the needs of the residents so that staff know what residents need and like. There has also been training for staff so that they know what to do if they are concerned about residents’ well-being. Better training has led to the service receiving the Investors In People Award, and good kitchen standards have led to the Gold Award from the Environmental Health department. Walkden Manor DS0000062619.V335772.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. The summary of this inspection report can be made available in other formats on request. Walkden Manor DS0000062619.V335772.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 Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents have basic information about the service, providing limited awareness of how the service will be able to meet their needs. EVIDENCE: The manager stated that a brochure and service users’ guide is given to residents new to the home. The guide was in the foyer and contained information about the service, but some information was out of date, such as contact details for the CSCI. Other details were not included, such as residents’ views, and ways in which the service meets the needs of people with dementia, and the document is not available in different formats. Residents have an assessment of their needs carried out by the manager before admission. The assessment includes a visit to the person in their own home, or in hospital, by talking with the individual or with family members. A recently completed pre-admission assessment showed that physical care needs were included, but social and cultural needs were not noted. Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ basic health and personal care needs are met. EVIDENCE: Care plans have improved since the last inspection, covering a range of topics that include ways in which care staff should address emotional as well as physical health needs. Nutritional and pressure area risk assessments are in place and reviewed monthly. However, examples of inaccurate information such as wrongly recorded weights posed the risk of ineffective monitoring of residents’ health. One person appeared to have lost weight according to the records, but further investigation provided evidence that there had been no weight loss. In one file, two other residents’ names were mistakenly used in parts of the person’s care plan. The plans for people with dementia did not sufficiently reflect their individual needs and the ways in which those needs are to be met. Comments made by residents indicated that they were satisfied that their basic needs were met most of the time, but also felt that they were kept waiting when they needed assistance at times. One person said “the carers are good Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 Page 10 and caring”. Another said “They keep me waiting, sometimes there is no-one around to ask for help”. Staff members were seen to be patient and sensitive when assisting residents, and providing reassurance to people who were anxious, particularly those people with dementia. Medication arrangements were safe and suitable, ensuring that residents have the correct medication administered by staff trained to do so. Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Meals at the home are varied, nutritious and enjoyed by residents, but activities do not fully take account of individual needs. EVIDENCE: Residents consulted were satisfied that they are able to exercise choice in their daily routines. One person said “we can get up when we want to, and what we do is up to us”. They confirmed that some activities take place such as bingo and exercise in the form of “Healthy Heart and Hips” sessions, but that they would like more activities. An outing to Smithills Hall was also due to take place, and staff said that they often take residents out on their days off, indicating that time to do this was limited when they were on duty. There was inadequate evidence of the ways in which the needs of people with dementia were being met in terms of their recreational needs. There are open visiting arrangements. Residents confirmed that their religious needs are met through communion at the home each Sunday morning. Meal provision was good, with the cook having a very good knowledge of each resident’s preferences and dietary needs. The cook serves meals and clearly takes an interest in making sure that people eat well and have food presented in a palatable way. Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18:Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents feel that issues they raise will be dealt with, and staff training arrangements seek to promote the protection of residents from abuse. EVIDENCE: Residents consulted during the site visit, and in survey responses confirmed that they are aware of the procedure for making complaints, and had confidence in the manager to respond appropriately to any issues they wanted to raise. The service has received six complaints in the last 12 months. A record is kept of all complaints along with the outcomes and response. Information about advocacy services is displayed in the entrance to the home. Adult protection and whistle-blowing policies are in place, and staff consulted were aware of the contents and the actions to take in response to any suspicions of poor practice affecting residents’ welfare. Training has also been provided for staff to ensure they have a full understanding of protection issues. However, shortfalls in recruitment procedures compromise residents’ safety. The manager was aware of the circumstances in which staff should be referred to the Protection of Vulnerable Adults register. Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in homely and safe surroundings. EVIDENCE: Residents live in generally homely surroundings and are encouraged to personalise their bedrooms. Some areas of the home have been redecorated since the last inspection and improved standards of cleanliness have been introduced. Paper towels were not available in the staff toilet to assist with infection control. This was addressed during the visit. Fire safety records include regular, recorded checks on the emergency lighting or means of escape, and regular fire drills are carried out. Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30: Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing arrangements and unsafe recruitment practices do not safeguard residents’ welfare. EVIDENCE: It was not possible to determine the numbers of staff on duty as there was no record of which staff had worked on each shift at any time. The manager stated that there was a “rolling rota” and this was seen, but this indicated that there were only two staff on duty on some mornings and one at night at times. As the rota does not reflect the numbers and names of staff who were on duty on any given date, it was not possible to determine if sufficient staffing levels are, or have been maintained. When asked about it, one staff member said “we understand it, and we can tell who was on if they wrote in the diary because of their handwriting”. In terms of training, a high proportion of staff have achieved NVQ qualifications, but the manager acknowledged that several staff have not received refresher training in mandatory topics including health and safety, infection control, food hygiene and fire safety, and there was no training plan or timetable to show when training was due or had taken place. There were major shortfalls in recruitment practices identified in the staff files examined. These included unreliable references with the position of one referee unknown, one from an employee’s ex-colleague from 2005, no evidence of a follow-up to unclear information, and no exploration of gaps in employment. One person started employment before the POVA First check was received. Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 Page 15 Another staff member had no background checks carried out when she was reemployed following an absence of six months. Records indicated that induction training for new staff took place over the course of one day and mainly covered practical and orientation topics about the home. The records were not dated and, in one instance, not signed by the care worker or the manager. Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38: Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The way in which the service is managed does not promote residents’ best interests. EVIDENCE: The manager has achieved NVQ4 and the Registered Manager’s Award. Residents consulted said they liked the manager, and commented that “she is cheerful and talks to us”. However, the shortfalls identified, such as inadequate staff recruitment procedures, training plans and rotas, indicate that management practices do not adequately promote the welfare of the residents. Furthermore, the monthly audits carried out by the area manager have failed to identify the shortfalls listed. The quality assurance system relies on written questionnaires and seeks the views of relatives but not residents. There was no evidence of views obtained from visiting social care or health professionals. The response to Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 Page 17 relatives’ views has been included in a newsletter, but the newsletter has not been sent to anybody. The manager stated that only herself and senior staff members have access to the keys for accessing residents’ monies. Records of transactions were in place. There have been two incidents of theft at the home, one in January 2007 and another came to light on the first day of this inspection visit. The manager has started to review the arrangements in place to protect residents’ monies to ensure they are secure, and future incidents are averted. Fire safety equipment and gas and electrical appliances are regularly serviced and tested. Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 X X 3 Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 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 OP1 Regulation 5 Requirement A service user guide that accurately describes the service and facilities must be produced, and provided to residents in a suitable format so that they know what to expect of the service. Care plans must accurately describe and reflect personal, social and dementia care needs of residents so that they receive individualised support. Previous deadline of 20/12/06 not met. Arrangements must be made to ensure that residents have their individual recreational needs identified and met. There must be sufficient numbers of staff on duty at all times to meet the assessed needs of residents. Robust recruitment arrangements must be implemented in order to protect the welfare of residents. A training plan must be produced and implemented to ensure that residents are supported by staff trained in mandatory topics DS0000062619.V335772.R01.S.doc Timescale for action 01/10/07 2 OP7 15 01/10/07 3 OP12 12 (2) 12(3) 16(2) 18(1) 01/10/07 4 OP27 01/08/07 5 OP29 19(1) 03/07/07 6 OP30 18(1) 01/10/07 Walkden Manor Version 5.2 Page 20 including health and safety, infection control, food hygiene and fire safety. 7 OP33 24(1) A quality monitoring system must be implemented to ensure that the service is managed in residents’ best interests. 01/10/07 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 OP3 Good Practice Recommendations Pre-admission assessments should include the social and cultural needs of residents so that the suitability of the service to meet those needs may be determined. Walkden Manor DS0000062619.V335772.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - 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. 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