Care Home: Pendlebury Manor Care Home

What the care home does well The manager visits people wherever possible to carry out an assessment of their care needs before they move in to the home to ensure that their needs can be met there. Good information is given to prospective residents so that they can make an informed choice of whether the home is the right place for them to live. Individualised care and attention is provided and there is a welcoming cheerful environment so that people who are cared for feel comfortable and at home. People`s plans of care were well documented and reflected each person`s individual needs. We found people receive care and support that matches their expectations. Staff have a good understanding of the importance of treating people as individuals and promoting their privacy and dignity. Survey forms received by CQC stated " " the care and attention given to residents is very good and the overall running of the home is excellent" " the home is in a good phase at this time" " there is a good nucleus of caring staff" Meals were varied and offered choice and variety. The kitchen was cleaned to a high standard. People spoken with said " the meals are good" " I am never hungry, food is lovely." People who live at Pendlebury Manor have choices about how and where they spend their time and the home provides a varied range of activities so that people have enough to do. A good standard of hygiene was seen throughout the home and the standard of decor was good. Staff were seen to treat people they cared for with respect and had an easy friendly manner. One relatives survey said" I am always made welcome" The home is now managed by a well qualified and experienced management team. Staff, residents, and their visitors are given opportunities to express their views about the home. This helps to make sure the home is run in a way that suits residents` needs and preferences. Good recruitment procedures are followed to make sure new staff are suitable to work with vulnerable older people. All new staff complete a thorough induction programme to make sure they know how they should provide care for the people who live at the home. Most of the care staff have an national vocational qualification (NVQ) in care so they have the knowledge and skills to provide care for the people who live there. These are nationally recognised qualifications for people working in care and show they have been assessed as competent to provide good quality care. What has improved since the last inspection? Staff have received training with regard fire safety, moving and handling and safeguarding adults so that they are aware of how to keep people safe and are able to move people safely. Regular formal supervision is now taking place on a regular basis for all staff to ensure that they have the opportunity to discuss any concerns they have and are given the support they need. Auditing systems are in place so that management at the home can identify problems quickly and rectify them within a firm timescale. What the care home could do better: Pendlebury Manor provides a good service to the people who live there. This is confirmed by the people themselves and the staff. No requirements or recommendations have been made as a result of this inspection. We saw evidence that the manager is looking at ways to improve the service they provide. Key inspection report Care homes for older people Name: Address: Pendlebury Manor Care Home Lyme Green Park London Road Lyme Green Macclesfield Cheshire SK11 0LD     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Joan Adam     Date: 2 5 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 24 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 24 Information about the care home Name of care home: Address: Pendlebury Manor Care Home Lyme Green Park London Road Lyme Green Macclesfield Cheshire SK11 0LD 01260253555 01260251641 pendlebury.manor@virgin.net Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Pendlebury Care Homes Ltd Name of registered manager (if applicable) Mrs Bernadette Sumner Type of registration: Number of places registered: care home 61 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: The Registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of service users who can be accommodated is: 61 Date of last inspection Brief description of the care home Pendlebury Manor provides care for up to 61 people with dementia who require personal care only. It is situated on the outskirts of Macclesfield. The home is divided into two units the Villa and the Manor. Accommodation comprises of 53 single rooms and 4 shared rooms. There are dining and lounge areas in each unit and two passenger lifts for access to the first floor. There is adequate car parking facilities at the home. Care Homes for Older People Page 4 of 24 Over 65 0 61 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We carried out an unannounced visit to the home on Th May 2010 and the visit lasted seven and a half hours. It was done by two inspectors. The report will say we when referring to what was done and found at the visit, as it is written on behalf of the Care Quality Commission. This visit was just one part of the inspection. Before the visit the manager was asked to complete a questionnaire to provide up to date information about the home. We sent out questionnaires to the people who live in the home and the staff team to find out their views about Pendlebury Manor. Other information about the home was also reviewed. During our visit we looked at various records and the premises. We looked at the care records of four people who live at the home, to see how their needs were being met. We also looked at four staff files to ensure that thorough recruitment processes had Care Homes for Older People Page 5 of 24 taken place and that people who live in the home were safeguarded from harm and supported safely. We spoke with some of the people who live at Pendlebury manor,the manager and other staff who were on duty at the time of this visit. They all gave their views about the home. Care Homes for Older People Page 6 of 24 What the care home does well: What has improved since the last inspection? Staff have received training with regard fire safety, moving and handling and safeguarding adults so that they are aware of how to keep people safe and are able to move people safely. Regular formal supervision is now taking place on a regular basis for all staff to ensure that they have the opportunity to discuss any concerns they have and are given the support they need. Auditing systems are in place so that management at the home can identify problems quickly and rectify them within a firm timescale. Care Homes for Older People Page 7 of 24 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 24 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 24 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People received information about the home to help them decide about moving in and their needs are checked before they move in so they know that these can be met at Pendlebury manor Evidence: We saw a copy of the information that tells people how the home works, the service users guide and statement of purpose.The service users guide contained information on accommodation, services provided, staffing, care plans and care programme, and the complaints procedure for the home. This document was in the process of being up dated. A document was available for staff to use with people before they move into the home to check on what their needs are. This covers personal details, next of kin, GP, mental health assessment, mental capacity assessment and best interests checklist. Prospective residents have the opportunity to visit the home for gradually extended periods of time starting with being shown around the home, then spending time with Care Homes for Older People Page 10 of 24 Evidence: residents and sharing a meal, to overnight or weekend stays before people have to make a decision to move in. Care Homes for Older People Page 11 of 24 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Pendlebury Manor have their health,personal and social needs met in a dignified way. Evidence: The AQAA showed us the the people who live at Pendlebury Manor should expect to receive care in a way that they choose. We saw that each person had a plan of care, which gave staff instructions on how to provide care in a way which people preferred. The care plans were written well and reflected the individuals needs. All plans of care were reviewed each month so that any changes were up dated and all staff would know what changes if any had been made. A moving and handling assessment had been completed on each resident so that staff would know how to move them safely. A nutritional assessment had been filled in so that staff would know if the residents were at risk of losing weight. Weights were recorded on a weekly or monthly basis to make sure that people were staying at an appropriate weight for them. Peoples choices about their daily routines were recorded in their care files, including when they liked to get up, where they spent their day and how their spiritual needs were met. This helped staff to make sure that people were able to follow the daily Care Homes for Older People Page 12 of 24 Evidence: routines of their own choice. Visits from other health care professionals such as GPs, nursing home co-ordinators and district nurses were recorded so staff would know when these visits had taken place and why. The daily records were detailed so that all staff would know what had taken place during the shift. The manager audits the care plans on a monthly basis so that areas of concern can be acted upon quickly. A care plan looked at was seen to have some documents which were not fully completed, this was discussed with the manager at the time of the visit. The home had a warm and welcoming atmosphere and all staff were seen to be friendly and appeared to have good relationships with the people in their care. People spoken with said It is pleasant here the staff are very nice Survey forms received by us from relatives had comments such as Care and attention is very good a good rapport has been established with staffstaff are very caring to residents Medicines were managed well. Policies and procedures were in place for the safe management of medications and staff training had taken place so that staff were aware of their responsibilities regarding the safety of medicines in the home. Medication that was in the home had been accounted for. All medication administration sheets had been completed properly. We looked at the management of controlled drugs and found these had been checked and recorded properly. Items with a short shelf life in the drug fridge had been dated and signed so that staff would know when these had been opened. The medication management was audited every month so that any errors were identified and dealt with quickly. All this helped to make sure that the medicines were properly managed in the home so that people received them as their doctors had prescribed, safely and without errors. Care Homes for Older People Page 13 of 24 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Pendlebury Manor are able to take part in a range of activities and mealtimes were a positive experience. Evidence: We looked at the AQAA which told us that the provision of activities on offer is varied and takes in to account the needs and wishes of the people who live in the home. When we visited we found this to be true. A further activities co-ordinator has been employed and activities on offer are move to music, quizzes, sing-along, reminiscence, floor games. reading groups, jigsaws, arts and crafts, slide shows, nails and beauty and reading and daily newspapers. People who live in the home were seen to assist in setting of tables prior to lunch being served. A barge trip had been arranged to enable some residents to go out . The menu is varied and the food on offer looked good. choices are available and alternatives are offered if someone does not like what is on offer. Staff were seen to assist people to eat in a relaxed and dignified manner. Care Homes for Older People Page 14 of 24 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Pendlebury Manor are confident that their complaints are listened to and staff have received training so that they know what to do to protect people. Evidence: We looked at the AQAA which told us that three complaints had been made to the home. One complaint has been received by CQC. It also told us that staff have received training in how to protect people rights and the complaints procedure.We made a short visit to the home in January to check the requirements from the last big visit and a majority of staff had received this training, therefore the requirement had been met. The home had policies and procedures on the prevention of abuse and whistle blowing. The safeguarding procedure is how the local council and other agencies respond to allegations of abuse against vulnerable people. Care Homes for Older People Page 15 of 24 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in Pendlebury Manor live in a clean, comfortable well maintained environment. Evidence: We looked at the AQAA which told us that there is an ongoing programme of maintenance and replacement. The home has been redecorated within the last twelve months and is pleasant. A good supply of equipment is available to assist staff to care for people appropriately including gloves and aprons to assist in the prevention of infections. Care Homes for Older People Page 16 of 24 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Pendlebury Manor are supported by staff who have gone through a thorough recruitment process, so that peoples needs are met and they are safe from possible harm or poor practice. Evidence: We looked at the homes AQAA which showed us that a variety of staff are employed to provide care and support to the people who live in the home and that the staff was recruited correctly. We found this to be true. This has improved since the last big visit. We made a short visit to the home in January to check if this requirement was being met. We found that staff are supplied in sufficient numbers to meet peoples needs and people who live in the home said they thought that there was enough staff on duty on each shift. We saw that some of the staff working in the home have achieved a national vocational qualification in care. This shows that staff have had formal training to carry out their roles and is above the expectations of the national minimum standards. Other staff members are undertaking the course and a further number of staff have been enrolled to commence in the near future. We saw staff training is on-going and that all staff have received mandatory training in key subjects. This means that staff have been given the skills to promote peoples health and welfare. Staff spoken with confirmed that training has taken place. The home are using the Mulberry training at Care Homes for Older People Page 17 of 24 Evidence: present and it was discussed with the manager that external training sessions should be utilised to work along side of this. Care Homes for Older People Page 18 of 24 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and the views of people who live there are obtained to meet their needs. Evidence: The manager of the home is an experienced manager who has attained the relevant management qualifications and has been registered with CQC. She is supported by senior care staff who have attained an NVQ level 3 in care. Staff spoken with said that they feel supported by the manager of the home and that the home has improved since she has been in post. She had completed the information about the home we ask for each year, the annual quality assurance assessment (AQAA) that gave us information about the home and what had been happening there during the twelve months before our visit. This information gave us a good overview of how the home was being run and was very detailed. We looked at how the people who live at the home and their relatives are consulted Care Homes for Older People Page 19 of 24 Evidence: about the service. We found that regular meetings with the manager are held and minutes taken to circulate to all who were at the meeting and for others who did not attend so that they are aware of what has been discussed. Surveys have been sent out to families from the home and comments such as staff are very friendly and always helpful there has been an improvement to management and activities. The AQAA said that All staff including catering, housekeeping and maintenance work well as a team and provide a homely and safe environment for residents. We welcome suggestions and comments from our residents, families and other health and social care professionals to improve the service delivered and to ensure the rights, privacy and dignity of our residents is respected at all times. We looked at how the health and safety of the people who live at the home is protected and found that there are regular checks on all equipment. We also saw that necessary checks are carried out to the services of the building. Care plans and medication management are audited on a monthly basis so any errors can be highlighted and acted upon quickly. Staff training is up to date and is recorded appropriately so that the manager can see which staff have received training and when. Recruitment at the home is robust so that the manager is sure the people who work there are safe to work with elderly people. Staff are supervised on a daily bias and formal recorded supervision takes place so that Care Homes for Older People Page 20 of 24 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 18 18 All staff must receive up to date training regarding safeguarding of adults so they know how to recognise abuse. 30/09/2009 2 27 18 Action must be taken to 31/08/2009 make sure there are adequate numbers of staff deployed in the home to meet the needs of the people living there. 3 30 18 All staff must receive training 30/09/2009 with regard to dementia care so that the needs of people living in the home can be fully met. Adequate arrangements 04/09/2009 must be made for all staff working in the home to receive suitable training on fire safety and take part in fire drills. This is to make sure that they know what to do to protect people living in the home if fire breaks out. This is an unmet requirement with a previous timescale for compliance of 05/11/08 4 38 23 Care Homes for Older People Page 21 of 24 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 5 38 24 The quality assurance 30/09/2009 system must be in place so that areas of concern or that need improvement can be highlighted and acted upon quickly. 6 38 18 All staff must receive up to date moving and handling training so people living in the home are not placed at risk of possible injury. 30/09/2009 Care Homes for Older People Page 22 of 24 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 23 of 24 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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