Latest Inspection
This is the latest available inspection report for this service, carried out on 20th August 2008. CSCI found this care home to be providing an Good service.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
For extracts, read the latest CQC inspection for The Manor Nursing and Residential Home.
What the care home does well Staff at The Manor Nursing and Residential home is able to meet the needs of the people who live there. People who spoke with the inspector said that they were pleased with the care and service they received everyday from all the staff that cared for them. The atmosphere at the home was relaxing and pleasant. What has improved since the last inspection? The overall appearance of the home continues to be improved with an ongoing maintenance programme. This is beneficial to the people who work and live there. Changes have been made to the recruitment policy with a review to the application form, equal opportunities and interviewing packs to ensure a better system is used for the recruitment process. What the care home could do better: A review of the staffing levels may be advised so that when the carers are not able to be in the lounge area on one side of the care home staff can be present should anyone else in that area need assistance. CARE HOMES FOR OLDER PEOPLE
The Manor Nursing and Residential Home 78-80 Lutterworth Road Aylestone Leicester Leicestershire LE2 8PG Lead Inspector
Lesley Allison-White Unannounced Inspection 20th August 2008 13:00h 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 The Manor Nursing and Residential Home DS0000001919.V370457.R02.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. The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Manor Nursing and Residential Home Address 78-80 Lutterworth Road Aylestone Leicester Leicestershire LE2 8PG 0116 2990225 0116 2990257 themanorcarehome@hotmail.com themanorcarehome@hotmail.com Mr Bassir Jugon 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) Manager post vacant Care Home 49 Category(ies) of Dementia (49), Dementia - over 65 years of age registration, with number (49), Learning disability (23), Learning disability of places over 65 years of age (23), Mental disorder, excluding learning disability or dementia (23), Mental Disorder, excluding learning disability or dementia - over 65 years of age (23), Old age, not falling within any other category (49), Physical disability (49), Physical disability over 65 years of age (49) The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No person may be admitted to The Manor Nursing and Residential Home who fall within the category / combined categories MD, MD (E), LD, LD (E), when 23 persons who fall within any category / combined categories are already accommodated within the home. No person under 55 years of age who falls within categories DE, MD, PD or LD may be admitted to The Manor Nursing and Residential Home No one falling within category OP may be admitted into The Manor Nursing and Residential Home where there are 49 persons of category OP already accommodated within the home The maximum number of persons to be accommodated at The Manor Nursing and Residential Home is 49 28th September 2007 2. 3. 4. Date of last inspection Brief Description of the Service: The Manor Nursing and Residential Home is a large establishment situated on the Lutterworth Road formerly a large house it has been re-developed and comprises of two houses numbers 78 and 80. It is within easy reach of Leicester by public transport or car. The home offers accommodation for up to forty-nine residents with nursing, residential, mental health, and learning disability needs. The home also offers respite care facilities and is set in extensive mature gardens, which are mainly laid to lawn with shrub borders. There is a conservatory and also a covered area, which is occasionally used for activities or as a quiet area for visitors. The home has two dining room/ lounges. The home has a number of shared rooms and some bedrooms are en-suite. Both floors are accessible to residents by either a passenger or stair lift. All rooms are fitted with smoke detectors and nurse call systems. There are ample parking spaces and a number of local hotels and public amenities are within close proximity of the home. Fees range from £290.00 to £979.00 per week. The Statement of Purpose and Service User Guide (information about the service provided) are readily available. The Employers Liability Certificate of insurance is clearly displayed in the
The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 5 entrance hallway. Also seen was the Registration Certificate from the Commission of Social Care Inspection (CSCI) and a copy of the last inspection report is available on request. The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes.
The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is on outcomes for residents and their views of the service provided. The home provides care for up to forty-nine people. On the day of inspection there were forty-seven people living at the home. The inspection took five and a half hours to complete. Preparation included examining inspection records and looking at the service history and annual quality assurance record (AQQA). This is information sent into CSCI when requested about the service that is provided at The Manor Nursing and Residential home. A discussion was held with four people who lived there. The primary method of inspection used was “case tracking”. This involved speaking with or observing the people who use the service provided, looking at two peoples care plans and making observations. Care plans are records about the care or support provided for an individual. All the required key standards were inspected during this visit. There were no previous concerns and no requirements were made at this inspection. The acting manager a senior member of the care staff and one of the owners assisted the inspector. What the service does well:
Staff at The Manor Nursing and Residential home is able to meet the needs of the people who live there. People who spoke with the inspector said that they were pleased with the care and service they received everyday from all the staff that cared for them. The atmosphere at the home was relaxing and pleasant. The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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. The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 8 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 The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 9 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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is good and the pre-admission process ensures that the needs of the people living at this home will be met. EVIDENCE: The acting manager does the assessments. The Statement of Purpose and Service User Guide can be seen in different peoples bedrooms on a rack on the wall. Pre-assessments take place before a person is admitted to the home. People wanting to stay at the Manor are still being encouraged to have a trial period of one month to ensure that they like the home and to ensure that the staff can meet their needs. One individual who spoke to the inspector explained that their family selected the home for them and that they were happy to be at the Manor. Their family said that they were impressed by the care home when they visited it. A
The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 10 relative also said that as her relative was unable to make the choices they made the selection for them and were not disappointed. Another factor that helped was the location of the Manor making visiting easier. Standard 6 Intermediate care is not offered at his care home. The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People feel able to make choices for themselves and felt that they were well cared for by the staff. Those less able, have their needs set out in care plans that the staff aims to follow. EVIDENCE: Two care plans were inspected. Care, social and mental needs were addressed. New paper work is being tried and tested at the home to make information clearer and to encourage the carers to use the care plans more effectively. One individual’s care plan included assessments that were easy to follow and gave guidance as to how the care needs of the individual should be met. Both care plans covered relevant areas for the individual’s needs and one of the care plans stated a risk to staff because of their gender. An appropriate key worker was selected to assist this person. The evaluation of this care plan showed that it appears to be working. Staff makes an effort to enable people to choose who delivers their care and respect their preferences
The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 12 Three other people who spoke with the inspector at different times during the day said that they were independent and able to make choices for themselves and felt that they were well cared for by the staff. On observation, interaction between the staff and people living at the home appeared relaxed and supportive of those individuals needing care. People’s comments included ‘all the staff have been nice to me’. ‘Nights are okay also, not noisy’. ‘If I had a problem or concern I would talk to the owner or the acting manager’. Family members who also spoke to the inspector also felt that they could approach any staff for assistance when needed and were regular visitors at the home. Relatives were asked about hospital appointments and said that the staff escorted people to hospital appointments and that they also were asked to help in this way. Relatives’ comments included ‘ when my parent was unwell I was informed by the staff’. ‘When my relative had an accident in the home I was contacted by the staff who went to hospital with them’. A blister pack system is used at the home. Medications are pre dispensed to foil containers for the staff to give the medicines from. It makes the medicines easier to give. Creams are given. However, they are ticked but not signed for by anyone. This was discussed with the acting manager who said that she would talk with the staff for this practice to change. There was some confusion over the name of a medication prescribed by the pharmacist on the blister pack who then typed something slightly different on the medicine sheet. This can cause confusion to any newer staff members giving medicines. This is a problem for the Pharmacist to amend and the acting manager said that she would contact them and have it amended. Another minor area was where an eye medication did not identify the eye it was prescribed for. This is an area that the nurses can easily rectify. There were no controlled drugs (CD’s) on the premises. The inspector observed a difficult situation involving the privacy and dignity of a person in one of the lounges. The staff present managed the situation well. The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 13 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff listens to the people living at the home and encourages contact within the community. EVIDENCE: An activities coordinator provides activities and uses the support of the staff when available. Some individuals are provided with one to one activities that relate to their past interests such as looking at photographs of their family album together. This activity also needs the help of the family members and a life diary for each individual is being produced. Most weekdays provide activities for individuals to take part in. The conservatory is now completed and provides another area for individuals and their families and friends to use. Flexibility within the rota to take people out on a one to one basis is available and was shown when an individual’s family requested that they go to a family wedding. The individual enjoyed the day and the family were pleased with the efforts made by the staff. The activities co-ordinator continues to work within the home with groups or with individuals. Some people who lived at the home said that they did not go
The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 14 out of the care home often. Some relatives felt that the activities were not enough. A few of the people who spoke with the inspector said that they were happy with the care at the home. This included someone that the inspector met at the last inspection. Food is considered to be very important and choices displayed on the menu board and are offered as displayed. Meal times are considered a social occasion and family members are encouraged to join in if they wish to. The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 15 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who spoke with the inspector explained what they would know what to do if they had a problem and knew that the acting manager, nurses or owners would address them. People living at this home are protected in this way. EVIDENCE: The Commission of Social Care Inspection (CSCI) has received two complaints about The Manor Nursing and Residential home since the last inspection. The complaints have been dealt with. People who spoke with the inspector explained what they would know what to do if they had a problem and knew that the acting manager, nurses or owners would address them. On the issue of the Protection of Vulnerable Adults (POVA) staff that spoke with the inspector were aware of the issues and had a good understanding of how to protect people in their care. The term ‘whistle blowing’ was not understood by all staff however they were able to say when the Police or Social Services would be involved and were reminded of the role of the CSCI in this matter also. There are policies and procedures for dealing with complaints and protection although they need updating with CSCI latest contact details. The complaints book was checked and satisfactory. The complaints procedure is included in the
The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 16 Service User Guide and Statement of Purpose. People living at this home are protected in this way. The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, pleasant and hygienic. EVIDENCE: Two peoples rooms were seen. Privacy was maintained by the use of a curtain in the double room seen. Another person living at the home who spoke with the inspector said that they liked their room. It was kept comfortable at all times. A nurse explained that the new flooring in the bathrooms is said to be working well. The acting manager said that the new flooring has helped to keep the home cleaner. Environmental risk assessments within the home continue to be carried out by the owner. The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are well supported by the culture and life style within the home and feel safe with the staff that supports them. EVIDENCE: The recruitment records of two members of staff were inspected and were satisfactory. The staff members were able to describe their induction process and training received whist working at the Manor and are part of an ongoing training programme. Many of the staff are from overseas and are experienced and qualified nurses in their own countries although they work as care staff within the care home. Over half the staff has a National Vocational Qualification (NVQ) level 2 in care or above. Staff felt that they would be able ask senior staff for help to deal with any care situation. People at The Manor Nursing and Residential home who spoke with the inspector said that they felt the staff were well trained and felt that they were able to provide for their needs.
The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 19 The staff rota indicated that people who lived at this home had their needs met although there were times when one of the lounges had to wait a while when the staff were busy attending to someone from that lounge. This was discussed with the acting manager who said that this would be considered now that the occupancy levels were higher and that the needs of the people were more dependent one side of the home. As the needs of the people living at the home changes this should be reflected in the numbers of staff available on that side of the building. The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 20 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed for the benefit of the individuals who live there. EVIDENCE: Although the quality assurance forms were not seen, feedback from the relatives present at inspection was positive about the care provided at the home. People living at the home were also satisfied by the care and choices that they made and said that they found the staff to be very helpful at all times. The management team was also approachable. Family members are asked to assist their relatives in financial matters and any small amounts of money invoiced separately. In this way the protection of individuals money is maintained.
The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 21 The Leicestershire Fire and Rescue service visited the premises on 1st July 2008 and have written to say that a satisfactory standard of fire safety was evident although it was not a comprehensive audit of all fire safety matters. An inspection from the food safety team took place on 12 August 2008. General standards were found to be good. As the acting manager has been unwell at the beginning of the year regular staff and resident meetings have not been as regular. A senior carer has been given promotion and has been given increased responsibilities including supervisions of junior staff and is coping with the new responsibilities. In this way the outcomes for the people who live at the Manor remain positive. The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 22 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 3 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 Manor Nursing and Residential Home DS0000001919.V370457.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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
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