CARE HOMES FOR OLDER PEOPLE
Canford Manor Nursing Home Manor Way Lee-on-Solent Hampshire PO13 9JH Lead Inspector
Michael Gough Unannounced Inspection 17th January 2006 10:00 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 Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Canford Manor Nursing Home Address Manor Way Lee-on-Solent Hampshire PO13 9JH 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) (023) 92 550437 Mr Christopher Imonikhe Mrs Kathryn Dawn Imonikhe Margaret Phyllis Harper Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability (5), Physical disability of places over 65 years of age (24), Terminally ill (5), Terminally ill over 65 years of age (24) Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users in the PD and TI categories cannot be admitted under the age of 44 years. No more than 5 service users in total can be accommodated in the PD and TI categories 16th August 2005 Date of last inspection Brief Description of the Service: Canford Manor is a care home providing nursing care for a maximum of 24 older persons. Service users can be supported in the following categories: Old age not falling within any other category (24) Physical disability/Terminally ill over 65 years of age (24), Physical disability/terminally ill (5). The home is located in a quiet residential area of Lee on Solent and is close to local amenities, shops and public transport. Accommodation comprises of 24 single rooms with en-suite facilities and is located on two floors. A shaft lift is provided to give easy access to the upper floor. There is a large lounge/dining area and a separate small lounge is also available. There is a rear garden which is accessible to service users and there is car parking at the front of the home. Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over 3 hours and was unannounced. The homes proprietors and the registered manager assisted the inspector’s during the course of the inspection. Evidence for this report was obtained by speaking with the proprietors, the homes manager, from reading and inspecting records, touring the home and from observing the interaction between staff and service users. It was also possible to speak with 8 service users, 3 members of staff and 2 visitors to the home. What the service does well: What has improved since the last inspection? What they could do better:
The inspection report will make 3 requirements, which will help improve the service provided for residents. Care plans had daily notes which gave information on how care was given however there was not always evidence that monthly reviews had been carried out and it is a requirement that care plans are regularly reviewed. There was not always clear information within individuals care plans to ensure that all needs were being met. It is acknowledged that the home is looking to further develop all of the care plans at the home and these will be looked at during the next inspection. Supervision is carried out at the home, however this is not always formal and recorded. It is a requirement that formal supervision takes place at least 6 times per year. Training records did not always provide clear evidence of
Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 6 training undertaken and the home is developing a new training policy, which will have induction and foundation training and will include a staff training and development programme. On arrival at the home the inspectors observed a fire door wedged open, the proprietor stated that this was due to the fact that he was working in the room, however it is a requirement that all fire doors at the home must only be held open by approved devices. 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. Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Each service user has a needs assessment carried out before moving into the home. EVIDENCE: Files were seen for 4 service users and needs assessments were available and on file. One of the homes proprietors carries out assessments using a standard form and the assessment includes admission information such as date of birth, next of kin, religion, GP plus information on the service users needs. The inspectors were informed that the home is updating its needs assessment form, however these were not available for inspection on this occasion. Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10 Service users health, personal and social care needs are set out in a plan of care and are generally met, however these are not necessarily reflective of care needs. There was not always evidence that monthly reviews had been carried out, therefore it was not clear if care needs were up to date. The health care needs of service users are generally met and service users are treated with dignity and respect. EVIDENCE: Care plans were seen for 4 service users and these gave information for staff on the care needs of individuals, there was evidence that risk assessments had been carried out and there was information on individual likes and dislikes, however there were gaps in the recording of monthly reviews of care plans and it is a requirement that care plans are regularly reviewed. Daily notes were recorded and provided evidence of the daily care given. One service user was calling out during the inspection and the inspectors were informed that the service user was confused. The inspector observed the service users in her room with a member of staff in attendance and she appeared much calmer. There was no clear information within this individuals care plan to ensure that any mental health issues were being met, however there was evidence that a psychological assessment had been carried out recently and that the GP was
Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 10 adjusting the service users medication. This issue was discussed with one of the registered providers and the homes manager. The inspectors were informed that the home is currently updating all of the care plans at the home and these will be looked at during the next inspection. The inspector spoke to 8 service user and 2 visitors to the home and they all stated that they are treated with dignity and respect, and that the home meets their individual needs. Service users receive their mail unopened and have access to a private telephone. Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Service users are supported to exercise choice and control over their lives. EVIDENCE: Service users spoken to confirmed that they are able to make informed choices and are able to control their own lives. They stated that they were consulted regularly and that staff at the home respected their views and that if they wanted anything all they had to do was ask. There were there are no restrictions on bathing or going to bed and their was evidence in care files of service users preferences for when they would like to go to bed and get up and the home ensured that service users wishes were acted upon. A number of service users had bought some of their own possessions into the home and rooms had been personalised. Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. EVIDENCE: Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 26 Service users have the specialist equipment they require to maximise their independence and the home was clean, pleasant and hygienic and free from offensive odours. EVIDENCE: The home provides a shaft lift to access the first floor and hand rails are in place around the home and in bathrooms. Aids, hoists and assisted baths are in use at the home and a number of service users use wheelchairs to get around. Wheelchairs in use had footplates in place; one service user dislikes using footplates and this is documented in the plan of care, along with a risk assessment. The inspector toured the building and all areas of the home were clean and tidy and furniture was in a satisfactory state of repair. Service users were seen to be using both of the communal lounges in the home and these were bright and airy. The home has a laundry and has dedicated domestic staff; there are 2 industrial tumble driers and washing machines with sluice programmes. Any soiled laundry is brought down in yellow bags so that it is clearly identified.
Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 14 Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 30 Staff morale was good and there was a good rapport between service users and staff. The home provides training for staff, however these were patchy and more accurate records are required. EVIDENCE: The home employs 10 trained nursing staff. There are currently 2 care staff that have completed NVQII with 1 staff member nearing completion. There is 1 staff member due to start NVQIII and 1 due to start NVQII. 2 domestic staff are undertaking NVQII in cleaning and support. The inspectors were informed that the home is developing a new training policy, which will have induction and foundation training and include a staff training and development programme and this will be looked at in more detail at the next inspection. Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 The registered providers support the home manager by providing updated polices and sharing nursing ideas and plans for the home. The home operates a limited quality assurance monitoring system to obtain the view of service users at the home. Service users financial interests are safeguarded by the home financial procedures. Staff do not receive supervison on a formal basis and it is not recorded. The health safety and welfare of service users are generally promoted and protected. EVIDENCE: The registered providers and the manager work closely together and have the required experience. The home carried out a quality assurance audit in August 2005 by means of a service users questionnaire, however the providers felt that the information gathered was limited and therefore it is not collated and published. The inspectors were informed that the home speaks directly to relatives and service users to ascertain how the home is meeting its aims and
Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 17 objectives, however this is not recorded. The home does not handle the financial affairs of any of its service users; it does however keep small sums of money on behalf of service users to pay for hairdressing chiropody etc. The hairdresser and chiropodist who visit the home provide an itemised bill and each service user is then charged individually. Service users money is kept by the manager in individual bags with full records kept. The manager at the home does not receive formal supervision, however there is regular communication between the manager and the registered providers. It is a requirement that all staff at the home receive formal supervision at least 6 times per year. On the day of the inspection the homes fire alarm system was being serviced and the fire logbook was inspected, this contained all relevant training, and testing is carried out. On arrival at the home the inspectors observed a fire door wedged open, the proprietor stated that this was due to the fact that he was working in the room, however it is a requirement that all fire doors at the home must only be held open by approved devices or as agreed by Hampshire Fire and Rescue Service. Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X 3 X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3 Standard OP7 OP36 OP38 Regulation 15 18 13 Requirement Timescale for action 01/04/06 It is a requirement that all care plans must be kept under regular review It is a requirement that formal 01/04/06 supervision must take place at least 6 times per year. It is a requirement that all fire 18/01/05 doors at the home must only be held open by approved devices, or as agreed by Hampshire Fire and rescue. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Canford Manor Nursing Home DS0000011493.V277869.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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