Care Home: Urmston Manor

Similar services:

• Chirnside House
• Keer Sands Residential Home
• Ruskin Lodge
• Bushell House
• Langrigg House
• Parkside
• Dystlegh Grange
• Thornton Lodge

What the care home does well Ensures that people`s needs are assessed to ensure that they are able to meet their needs. Provides adequate levels of support that ensure that residents care needs are met. Staff have a detailed awareness of resident needs and wishes. Provide a safe, comfortable environment for people to live. Provides a menu consisting of meals that residents enjoy. What has improved since the last inspection? New carpeting and blinds had been fitted to some areas of the home as part of an ongoing refurbishment plan. Improvements had been made to the labelling of medication. Some improvements had been made to the information relating to staff during the recruitment process. CARE HOMES FOR OLDER PEOPLE Urmston Manor 61-63 Church Road Urmston Manchester M41 9EJ Lead Inspector Adele Berriman Unannounced Inspection 12:30 17 & 31st January 2008 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.V353590.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Urmston Manor Address 61-63 Church Road Urmston Manchester M41 9EJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 747 6510 0161 755 3245 mands-collins@btinternet.com 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.V353590.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users will fall within the category of old age, but may in addition have a physical disability. 15th November 2006 Date of last inspection Brief Description of the Service: Urmston Manor is a care home registered to provide accommodation and personal care to twenty-four older people in twenty single and two double bedrooms. The home is located in a residential area of Urmston, Manchester. The home is set in spacious grounds with a pleasant garden area. There is limited parking at the rear of the building and space to park on the road at the side of the home. The home is on a main road with good access to public transport facilities into Manchester and surrounding areas. A selection of shops and Urmston market are close by. The home provides personal care within a broadly domestic setting to meet the needs of older people who do not have high dependency needs. The cost of the service is between £390.00 and £425.00. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 5 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. Two visits were made to Urmston Manor as part of this inspection. The first visit on the 17th January was unannounced. The second visit on the 31st January was announced as arrangements had to be made for the inspector to view records that are locked away. During the visits a selection of records, policies, procedures, care plans and medication. Five residents, a relative and a friend of a resident were spoken to during the visit. A tour of some areas of the building also took place. During both visits there was a warm, relaxed and pleasant atmosphere around the home. Throughout the visits observations were made of staff’s interaction with residents. These observations were very positive and staff demonstrated a good awareness of residents needs and wishes. Residents commented positively about care and support they received from the staff team. One resident described the staff as “champion” and that she is “looked after very well.” One resident told the inspector that she was very happy at the home and enjoys the company. Another resident said that she feels safe at the home and has no reason for complaint. All residents spoken to say that they liked the food served at the home. They also said that they would be happy to tell the staff if they were not happy about the service. What the service does well: Ensures that people’s needs are assessed to ensure that they are able to meet their needs. Provides adequate levels of support that ensure that residents care needs are met. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 6 Staff have a detailed awareness of resident needs and wishes. Provide a safe, comfortable environment for people to live. Provides a menu consisting of meals that residents enjoy. 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. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Urmston Manor DS0000005633.V353590.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from having their needs assessed to ensure that the service has the facilities to meet their needs and wishes. EVIDENCE: Prospective residents are invited to visit the home to experience life at Urmston Manor. During this visit peoples needs and wishes are assessed. This is to ensure that the home has the facilities to meet people’s needs and wishes. The managers of the home will visit people unable to visit the home themselves, so that she is able to assess their needs. The files of four residents were assessed during the visit and all contained a needs assessment. The format of the assessment gave the opportunity to record peoples needs and wishes relating to all aspects of their day-to-day life. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 9 Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care needs and wishes of residents were documented and known to staff, which ensured that people’s needs would be met. EVIDENCE: Each resident had an individual care plan booklet that gave the opportunity to record detailed information about people’s personal history, current needs and wishes and how these needs are to be met. Also included was information relating to what their day-to-day needs and wishes. Some of the documents contained detailed information about how the person’s needs were to be met. However, some records did not fully demonstrate what support a person needed, for example, one care plan stated that carers ‘need to assist out of bed and into bed.’ There was little indication of how staff were to actually assist the person. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 11 The manager of the service had devised a short care plan document that gave the opportunity to records important information about a resident, for example, personal and mobility needs and preferences relating to food etc. The manager stated that the purpose of the document was to provide a guide to residents care and support needs for newer or agency staff who may not be fully aware of the residents needs and wishes. Daily records formed part of the homes care planning procedures. Some of the records contained detailed information about the resident’s day. However, some records contained little information about the experiences of the resident during their day. For example, some records stated “fine all day. No problems.” Records demonstrated that residents had regular access to local healthcare professionals including their GP and district nursing service. Medication was stored in locked environment. However, the cabinet for storing controlled drugs was no longer appropriate as it did not conform to recent changes in legislation relating to the storage of controlled medication. Policies and procedures were in place to support staff in the administration of medication. Medication Administration Records were in use to record what and when medication had been administered. Not all of the information on these records had been completed, for example, the amount of medication received had not been recorded. Staff signatures occasionally overlapped several signature boxes; this practice should cease, as it was difficult on occasions to determine when medication had been administered. Staff spoken to demonstrate a detailed knowledge of resident’s medication needs and wishes. Throughout the visits staff were observed supporting residents in a respectful manner that promoted their dignity. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from being able to make choices about how they spend their day and what they eat. EVIDENCE: Various activities took place at the home. During the visits residents were seen playing dominoes and at another time having a sing-a-long. Outside entertainers visit occasionally. Information supplied by the manager stated that representatives from local churches visit the home to enable residents to practice their faith. Records demonstrated that one resident visited a local social group on a weekly basis. Residents confirmed that they were able to receive visitors at any time. A visitors’ policy is available in the entrance to the home. Residents indicated that they were able to make choice about what time they got up, went to bed, what they had to eat and whether they participated in activities at the home. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 13 The manager stated that it was her intention to improve over the next 12 months by compiling a new questionnaire to gain residents views relating to the meals and entertainment available at the home. An intercom system was in use throughout the building for resident to call for assistance at any time. Staff said that the system was turned on at night in all the rooms and that residents got comfort from knowing that they could just shout out for staff. All intercoms situated in residents bedrooms had been fitted with a privacy button to enable residents to have total privacy of required. It is recommended that the homes service user guide inform people of the facility. It is also recommended that resident’s choices around the use of the intercom be documented in their care. This would ensure that staff are aware of residents wishes regarding their privacy. A four-week menu plan was in place that gave residents access to a varied diet. The menu demonstrated that an alternative choice of meals were available most days at lunch and dinner. It is recommended in this report that the menu plan contains what options are available for supper. This would inform residents of what choice they have. All residents spoken to indicate that they were happy with the food served at the home and one resident said, “The food is very nice.” Meals were served in a pleasantly decorated lounge dining area. Tables were pleasantly set to ensure that residents found mealtimes a pleasurable and social experience. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were happy to raise any concerns they had about the service with the staff. EVIDENCE: The homes complaints policy was readily available for people to read. No complaints had been recorded about the service for some time. There had been no recorded complaints at the home or to the Commission. All residents spoken to during the visits stated that they speak to the staff if they had a concern/complaint about the service. Both staff that completed a survey form stated that they knew what to do if a resident or their relative had a concern about the service. A copy of the homes policy on abuse was available along with a copy of Trafford Social Services Adult Abuse policy. The manager stated that it was her intention for all staff to have the opportunity to attend adult protection awareness training with Trafford Care Consortium in 2008. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clean, comfortable and pleasant environment was provided for the residents. EVIDENCE: During the visits a pleasant and relaxed atmosphere was observed. Communal areas were pleasantly decorated and furnished with domestic style furniture. A selection of residents bedrooms were visited and all were furnished to meet their needs. Bedrooms had been personalised with resident person effects making each room individual. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 16 There was evidence of an ongoing plan of redecoration throughout the building. Since the last inspection new carpets had been fitted to some bedrooms. New carpeting throughout the communal areas had been ordered. During both visits the home was clean, tidy and free from any offensive odour. The fire detection system was tested on a weekly basis by senior staff. The emergency lighting system was tested four times a year. It is advised that the manager contacts Greater Manchester Fire and Rescue Service for advice on the appropriate frequency in which visual checks should be made of emergency lighting. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A consistent staff team that are aware of there needs and wishes supports residents. EVIDENCE: Three carers and a senior carer were on duty to meet the care needs of the residents along with a cook and an ancillary worker. One staff member wrote that the service could do better by ‘having extra carers on as sometimes we work short, and that’s not fair on the clients, as we cant spend as much time as we’d like to.’ During the visits staff were seen supporting residents in a supportive, professional and non-discriminatory manner. The inspector spoke to the senior carer on duty that demonstrated a thorough awareness of the residents’ needs and wishes. Three staff files were assessed during the visits. Most information needed to demonstrate that appropriate recruitment procedures had taken place was present on the files. However, one file did not contain evidence that a POVA 1st check or a CRB check had been carried out. It is essential that these Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 18 checks be carried out to ensure that only people suitable to work with vulnerable people are employed. There was evidence on staff files of training courses they had attended. The majority of staff had completed training in first aid, food hygiene and health and safety. The manager stated that refresher training in manual handling needed to be arranged and demonstrated further training opportunities that had been booked for the future through Trafford Care Consortium. Over 50 of staff had successfully completed an NVQ level 2 qualification. Residents commented positively about the care and support they received from the staff team. One resident said that the staff were “champion” and that she is “looked after very well.” Both staff that completed survey forms stated that they usually had the right support, experience and knowledge to meet people’s needs. One staff member stated that the manager of the service often meets with them to discuss how they are working. One staff member wrote “I only have to ask her to meet me if I have any problems” and the “manager always listens.” Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is sufficiently experienced and qualified to run the home; greater attention to sending notifications to CSCI and reviewing polices and procedures would continue to protect residents’ interests. EVIDENCE: The manager/provider of the service has many years experience of working in social care and has achieved her NVQ level 4 award. During discussion she demonstrated a commitment to ensuring that residents changing needs were addressed at all times. A selection of policies and procedures relating to maintaining the health, safety and wellbeing of all were assessed. These policies were available to staff at all Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 20 times. Some of the policies had been developed in 2003. It is recommended in this report that all policies and procedures are reviewed and updated on a regular basis. This is to ensure that they contain up to date information relating to changes in legislation. The manager stated that she was in the process of developing a new questionnaire to assess the views and opinions of the residents and their relatives about the service provided at the home. Accidents were being recorded on an appropriate format; however, completed forms had not been removed. Completed accident forms need to be stored in a manner that protects people’s personal information. Several entries into the accident book were situations that should have been reported to the Commission under regulation 37 of the Care Homes Regulations. It is essential that all accidents and incidents that have or potentially could affect the health and wellbeing of residents be reported to the Commission. Resident’s monies were stored in a secure environment and each person had their own account balance sheet. These records were maintained in an orderly manner. Residents wishing to maintain their own finances had a lockable drawer in their room for secure storage. Hot water outlets around the building were fitted with thermostatic controls to prevent scalding. It is recommended that the temperature of the water is monitored and recorded on a regular basis to ensure that the controls are operational. Information supplied to the Commission stated equipment and utilities had been tested and/or serviced within the previous twelve months. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Medication Administration Records must be completed in full to demonstrate a clear audit of medication. Criminal Records Bureau checks and POVA 1st checks must be carried out prior to a member of staff commencing employment. Timescale not met 18.03.06 and 31.12.06. All incidents and accidents that affect the health or wellbeing of residents are required to be reported to the Commission for Social Care Inspection. Timescale for action 24/03/08 2. OP29 19 24/03/08 3. OP37 37 24/03/08 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 OP7 Good Practice Recommendations A legally compliant controlled drug cupboard should be available to store controlled drugs to ensure they are not mishandled or misused DS0000005633.V353590.R01.S.doc Version 5.2 Page 23 Urmston Manor 2. 3. 4. 5. 6. OP7 OP7 OP9 OP14 OP15 7. 8. OP19 OP27 9. 10. 11. 12. 13. OP30 OP38 OP38 OP38 OP38 Medication Administration Records should be signed in a manner that demonstrates the actual time that the medication was administered. Information as to how a persons needs are to be met should be written in more detail in residents care plans. Residents care plans should contain information about their agreed ‘checks’ throughout the night. Daily records should record all activity of the residents. The index of the controlled drugs register should be completed and the practice of using ‘sticky’ labels on Medication Administration Records ceases. Information about the home’s intercom system should be written in the service user guide and that residents preferences relating to the use of the privacy button are recorded in the care plan. The menu should demonstrate what foods are available for supper. The manager should contact Greater Manchester Fire and Rescue Service for advice on the frequency of visual checks to the emergency lighting system around the building. A regular review of staffing levels should take place to ensure that sufficient staff are on duty at all times. Refresher training in moving and handling should be made available to staff. Completed accidents records should be stored in a manner that protects people’s personal details. All policies and procedures relating to the health, safety and wellbeing of residents are reviewed and updated on a regular basis. Regular checks of the hot water temperatures should be carried out and recorded. Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 24 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 Urmston Manor DS0000005633.V353590.R01.S.doc Version 5.2 Page 25 - 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!