Inspection on 08/05/08 for Canford Manor Nursing Home

This inspection was carried out on 8th May 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Canford Manor Nursing Home 15/05/07

Canford Manor Nursing Home 17/01/06

Canford Manor Nursing Home 16/08/05

Canford Manor Nursing Home 17/02/05

Canford Manor Nursing Home 29/10/04

Canford Manor Nursing Home 01/03/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Canford Manor Nursing Home 38 Manor Way Lee-on-Solent Hampshire PO13 9JH Lead Inspector Pat Trim Unannounced Inspection 8th May 2008 09:15 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.V363372.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. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Canford Manor Nursing Home Address 38 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 9255 0437 02380 559164 stannes@pegmar.co.uk Mr Christopher Imonikhe Mrs Kathryn Dawn Imonikhe Manager post vacant 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.V363372.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the PD and TI categories cannot be admitted under the age of 44 years. 15th May 2007 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. The home is located in a residential area of Lee on the Solent and is close to local amenities, shops and public transport. Accommodation comprises of 24 single rooms with en-suite facilities over 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 residents and there is car parking at the front of the home. Fees vary from £420.00 to £650.00 per week. The fee does not include toiletries, hairdressing, chiropody and items of a personal or luxury nature. Canford Manor Nursing Home DS0000011493.V363372.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 star. This means people who use this service experience good quality outcomes. The information used to write this report was obtained in the following ways. We looked to see if we had received any complaints about the home and saw that we had not. We also looked at any information the home had given us about what might have happened since we visited. We used some of the information the provider gave us about the home in a form called the Annual Quality Assurance Assessment (AQAA). This is a form the home has to fill out every year to tell us what they are doing to make sure the home gives the people who have used the service the care that they want. Some surveys were sent to people who use the service and their relatives but none were received back in time to inform this report. A six-hour visit was made to the home by one inspector to carry out a key unannounced inspection. During the visit time was spent talking with five of the people who use the service to get their views about it and five of the staff who worked in the home. Time was also spent discussing the provider’s plans for the home and looking at the environment. A random selection of documents was viewed. Three people who use the service were case tracked. This means their records were looked at to see how the provider identified their needs and made sure they were met. What the service does well: Canford Manor provides a warm friendly environment where people who use the service feel they can make decisions about how they live their lives. People who use the service said they decide when they get up and go to bed and where they spend their time. One person commented when speaking about the home: ‘I don’t think you could better it.’ People who use the service thought the staff were kind and did not rush them. Comments included: Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 6 ‘The staff are very nice and patient’ ‘I like to get up at 6 a.m. The staff come in every morning and help me wash and dress.’ Staff are able to go on training that helps them develop the specific skills they need to meet peoples’ individual needs. For example, recent training has included dementia and palliative care. Visitors are made welcome and feel they are kept informed about their relative. They are able to visit at any time and share the care of their relative. People who use the service said they liked the food provided and could choose alternatives if they wanted to. They liked the activities provided. What has improved since the last inspection? What they could do better: The providers identified in their AQAA a number of areas they wished to develop. These included developing care plans that were more person centred and identified what each person wanted in respect of their care and daily living activities. People who use the service have asked for more activities and the provider is going to get staff more involved in this aspect of care provision. The importance of completing medication records accurately must be discussed with staff and the records monitored to be sure this is being done. The provider should liaise with the health and safety officer to make sure people who use the service are sufficiently protected against the risk of falling from the upstairs windows. The providers are continuing to try and appoint a registered manager. This will give more stability and continuity to the home for the benefit of people who use the service and staff. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 7 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. Canford Manor Nursing Home DS0000011493.V363372.R01.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 Canford Manor Nursing Home DS0000011493.V363372.R01.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. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed pre admission assessments are completed which means people who use the service can be confident they will only be offered a place if the home can meet their needs EVIDENCE: Mrs. Imonikhe said she always completed an assessment of need before someone moved into the home for a trial period. The AQAA stated that the assessment had been recently reviewed. Further amendments were planned to develop an assessment that looked at mental capacity in relation to the Mental Capacity Act. Information to complete the assessment was gathered from the person, their family and health care professionals such as ward staff. The files for three people who use the service were viewed to look at the assessments completed before they moved into the home. Each person had an assessment of need that identified what aspects of their care they would need help with. For example, one assessment identified someone was anxious Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 10 at night and would need reassurance. This information had been used to complete a night care plan that ensured the person received the reassurance they needed. A range of risk assessment tools was used to identify areas of concern. These included nutrition, moving and handling, falls and tissue viability. The assessments identified the level of risk on admission, together with an action plan to minimise the risk. For example, one assessment identified someone was at risk of developing pressure sores and needed a specialist mattress. This was provided on admission. Mrs. Imonikhe said that people were encouraged to visit the home before moving in. If they were not able to visit themselves, their families could come instead. One person said her family visited several homes before deciding they thought she should try Canford Manor. People who are considering moving into the home are given a copy of the statement of purpose for information. Canford Manor Nursing Home DS0000011493.V363372.R01.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. All care plans need to consistently have sufficient detail about what help is needed if all the people who use the service are to be confident they will receive personal care in the way they like it. Health care needs are well monitored and met. A policy and procedure, and staff training ensure medication is managed safely. People who use the service receive care in a way that respects their rights to privacy and dignity. EVIDENCE: The information gathered in the assessment is used to complete a care plan for each person who uses the service. The care plans of the three people being case tracked were viewed. Two of these plans were very detailed, recording what the person could do for themselves as well as what help they needed. For example, one plan recorded that the person could wash their own hands and face, but needed help with washing the rest of their body. Night care plans were detailed and recorded the needs and identifying how to manage them. However, the third plan contained only brief guidance, such as someone needed help with washing and dressing. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 12 The AQAA identified the provider was going to develop plans that were more person centred and Mrs. Imonikhe said she was aware of the need to make sure all plans reflected the personal choice of people who use the service. The AQAA also recorded that since last inspection the home had introduced health care monitoring tools. These were seen and they and the risk assessments completed on admission were used on a monthly basis to monitor and review the care provided. Plans were amended to reflect the changing needs. The AQAA stated that care plans are reviewed with service users and their relatives but the people who use services had not signed their care plans, to evidence they had been involved in completing them. However, people knew what help staff were expected to give them and confirmed they received their care in the way they liked it. Those who required it had a separate nursing plan so that qualified staff knew what nursing care individual people needed. Health care needs were monitored, using the risk assessments already referred to. A record was kept of any health care professional visits and nursing interventions. People who used the service said they were able to see health care professionals such as doctors and chiropodists when they needed to. Daily records showed that doctors were called when required and people had access to health care services such as the chiropodist on a regular basis. The morning medication routine was observed. The qualified member of staff leading the shift is responsible for giving out the medication from the medicine trolley. Each person was given their medication with a drink and then the record signed to evidence it had been given. The records for two of the three people being case tracked were seen. These had been completed correctly. However, it was noted that another record had been completed incorrectly. The morning entry for an injection had been completed for ‘Friday’ on Thursday morning. The staff giving medication checked the signature and said the night staff had completed the wrong record. This was because another member of staff had already completed the ‘Thursday’ entry. The staff giving medication stated that the person who had signed the ‘Thursday’ entry would not have given the injection but had probably signed in error. She checked to confirm this and the member of staff was contacted to also confirm she had not given an injection. Mrs. Imonikhe said she would discuss the importance of completing medication records accurately with both the staff concerned. Mrs. Imonikhe said the nursing staff are able to attend medication training and had recently attended a course on drug assessment. Staff competency is assessed before they are able to give out medication and a record of signatures is kept so it is easy to identify who has given medication on any specific date. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 13 Medication is stored in accordance with Royal Pharmaceutical Guidelines with provision for the storage of controlled drugs. Records are kept of medication received into the home and unused medication sent for disposal. People who use the service said that staff treated them with dignity and respect. Staff were observed giving care discreetly and at the person’s own pace. Staff knocked on bedroom doors and waited for permission to enter. People who use the service are given information about their rights in the statement of purpose and are able to give feedback about the service they receive through questionnaires. Staff are given training about how to give care in a way that upholds peoples’ rights, through their induction and the completion of National Vocational Qualifications (NVQ). Eight of eleven staff have completed their NVQ. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 14 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. People who use the service are able to make choices about all aspects of their daily routine. Some activities are offered that provide mental stimulation and that people who use the service enjoy. The planned development of activities that are linked to people’s personal preferences will enhance their lives. People who use the service are offered a range of nutritious meals that they like. EVIDENCE: The three care plans viewed recorded information about the preferences of the people who used the service. For example, they recorded when the person liked to get up and go to bed and where they liked to eat breakfast. People who use the service said staff helped them to get up and go to bed when they wished and each had a routine that met their individual needs. For example, one person liked to get up about 8:30 a.m., have breakfast in her room and then come downstairs. Another person liked to get up at 6 a.m., get washed and dressed and come downstairs for breakfast. Both were helped to follow these routines. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 15 People who use the service said they enjoyed the activities provided by the home but would like more. They were not able to say what else they would like. The AQAA recorded that an activities co-ordinator had been appointed and a survey had been carried out identify what activities people who use the service would like to see provided. The co-ordinator was trying to compile a record of each person’s previous history, which would include hobbies and activities. Mrs. Imonikhe said this information would be used to provide suitable activities. At present the co-ordinator comes to the home once a week, but the AQAA identified that staff were to be encouraged to join in and support her with activities. Mrs. Imonikhe confirmed she was going to develop the initial assessment to provide more information about the social and emotional needs of people who use the service. She said she was also encouraging staff to join in and provide more activities. Currently, the home has regular visits from an entertainer who sings and a fortnightly music to movement class. Mrs. Imonikhe said the home also has regular visits by representatives of three local churches and people who use the service confirmed this. Throughout the day visitors came to the home. Some took their relatives out, whilst others spent time in the lounge. Those spoken with said they were always made welcome; one visitor regularly stays for lunch. All felt they were able to speak with Mrs. Imonikhe to discuss any issues and that communication between them and the home was good. People who use the service were asked where they would like to see their visitors and had the choice of staying in the main lounge, going to the quiet lounge or using their bedrooms. The home has a visiting hairdresser. Some people who use the service said they chose to use her, whilst others preferred to have the hairdresser they had always used visit the home. People who use the service said they generally enjoyed the food provided. They said there was only one main menu, but they could choose an alternative if they wished. A record was kept of individual choices. There was a supply of fresh fruit and vegetables available. The cook confirmed they were ordered weekly. Several people who used the service liked to have fresh fruit for pudding each day and were seen to be able to have this. Two people said they would like more choice of pudding. The menu plan showed that their requests had been listened to and the puddings they wanted included in this month’s plan. The cook said specialist diets could be provided if required. He confirmed that those who needed a sugar free diet could have the same puddings as everyone Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 16 else as a sugar substitute was used. Several people had to have liquidised meals. These were done so that each item was liquidised separately on the plate. Staff gave assistance to those who needed help with eating discreetly and at the person’s own pace. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 17 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 use the service have the information they need to enable them to make complaints. Staff have the training and information they need to protect people who use the service against the risk of abuse. EVIDENCE: The complaints procedure is included in the statement of purpose and a copy is displayed in the entrance hall. People who use the service said they knew how to make a complaint. They were able to speak to Mrs. Imonikhe and thought any concerns they raised were listened to and addressed. The AQAA recorded that two complaints had been made. A record of these was seen, together with the action taken to address them. A relative who had made one of them said the issue had been dealt with quickly and efficiently and resolved to her satisfaction. The commission had not received any complaints about the service since the last inspection. The home had a policy and procedure for safeguarding adults. Mrs. Imonikhe was reviewing this to ensure it complied with the latest guidance. Staff spoken with said they had regular training from Mrs. Imonikhe in relation to safeguarding adults and copies of certificates were seen. Mrs. Imonikhe had completed a ‘Train the Trainer’ course and was shortly to attend refresher course. Training for new staff had been arranged for the day Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 18 after the inspection and comprised watching a video, group discussion and answering a questionnaire. Mrs. Imonikhe said safeguarding issues were also discussed during supervision. The AQAA stated that all staff were given a copy of the policy and procedure and required to sign to confirm they had received it. Staff spoken with confirmed they had a copy. Three staff were asked questions relating to safeguarding issues. Two were confident about what action they would be required to take. The third member of staff was new and was attending the training session arranged for the next day. Three staff files were seen and evidence that a thorough recruitment process is followed including Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 19 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 provides a clean, safe, pleasant and well-maintained environment for the enjoyment of people who use the service. EVIDENCE: People who use the service said they liked their environment and thought the home was kept very clean. They particularly liked having the small lounge where they could see visitors in more quiet surroundings than the main lounge/dining room. They thought they had been able to personalise their bedrooms, bringing their own belongings and furniture and said they enjoyed spending time there and in the communal areas. One person said she felt her room was too small. She had discussed this with Mrs. Imonikhe and had been promised a larger room when one became available. There is a large garden that people said they liked sitting in when the weather was warmer. All areas of the home are accessible to everyone and there is a Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 20 lift to enable people with limited mobility to go to either floor. Specialist equipment such as standing aids, hoists and assisted baths are available on both floors of the home. No bedrooms were seen that had unpleasant odours. The home employs cleaning staff and there is a rota to ensure all areas are regularly cleaned. Mrs. Imonikhe said there was a renovation programme and bedrooms needing redecoration were done before anyone new moved in. A requirement was made at the last inspection, for Mr. Imonikhe to seek the advice of Hampshire Fire and Rescue Service about the practice of propping open bedroom doors. The home had since had a fire safety inspection and the report was available to see. Requirements made from the report had been met. Mr. Imonikhe said he had asked for advice about the bedroom doors and it was felt the practice was safe as there were waking staff on duty 24 hours a day. A risk assessment had been completed for the doors. The home had received a recent Environmental Health food safety inspection, which it had passed with no requirements. It was noted that when Mrs. Imonikhe is not in the home staff are not able to access the office telephone, as the office is kept locked. They have to make and answer all calls using the communal telephone in the hall. This can compromise confidentiality as staff were heard making a very sensitive call where everyone could overhear what was being said. This was discussed with Mrs. Imonikhe who agreed this was not acceptable and said she would make arrangements so that confidential calls could be made without being overheard. There are good systems in place to control the risk of infection. Each floor has its own sluice and there is a laundry that is able to deal with personal items and soiled linen. Staff have access to protective clothing, but this is not always available upstairs. Mrs. Imonikhe has added a daily task to the cleaner’s schedule to ensure supplies are regularly renewed. Staff have access to regular training in infection control, with the last course attended on 2nd May 2008. Mrs. Imonikhe said the domestic staff were completing a course about MRSA. The AQAA recorded that all staff had completed infection control training. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 21 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. The home provides well-trained staff in sufficient numbers to meet the needs of people who use the service. The recruitment procedure makes sure risks to people who use the service are minimised. EVIDENCE: People who use the service, said they thought there was usually enough staff working in the home to meet their needs, although two felt they sometimes had to wait too long for help to go to the bathroom. Call bells were answered quickly during the day and staff said they felt there were enough of them on duty to carry out the work they had to do. Mrs. Imonikhe said she adjusted staffing levels to meet current needs and had recently increased the number of staff on duty in the mornings as the needs of the people who used the service had become more complex. The rota reflected this increase and staff confirmed an additional staff member had been allocated. The AQAA recorded that 50 of care staff had completed their National Vocational Training (NVQ). Two staff said they were working towards it and were expecting their trainer to call that afternoon. Staff said they felt they were encouraged to complete qualifications. The home has a thorough recruitment procedure that enables the provider to make sure only suitable staff are employed. The procedure requires Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 22 prospective staff to complete an application form and attend an interview. Checks are carried out that include obtaining Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks and two references, one of which is from the previous employer. Two staff spoken with confirmed these checks had been carried out. The records for three staff were viewed. These contained all the above checks, completed before the person was allowed to work in the home. Checks were also carried in respect of qualifications for the nursing staff. Mrs. Imonikhe stated that new staff are required to complete an induction that complies with the Skills for Care guidance. Staff work alongside experienced staff, are given time to read policies and procedures and complete an induction workbook that requires them to look at the principles of care. Staff are also able to attend a wide range of training courses. Courses arranged for this year include mandatory ones such as moving and handling and infection control and courses relevant to the care provided, such as stoma care. Staff have also been able to complete distance learning courses in palliative care and dementia. The home uses ‘train the trainer’ courses to enable in house staff to pass training on. The AQAA identified getting more of the qualified staff to complete this training as an objective for the coming year. Mrs. Imonikhe said training needs are reviewed during supervision and information about courses was displayed on the notice board. Staff said they thought they had good training opportunities and had found the dementia course particularly useful. There were records of staff supervision, which demonstrated they were having a minimum of 6 sessions a year. Mrs. Imonikhe said qualified staff were going to attend supervision training so she could delegate the supervision of staff to them. Staff confirmed they received supervision and that it was used to discuss issues and identify training needs. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 23 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. People are able to give feedback about the service they receive. However, people who use the service and staff would benefit from having a registered manager who is available in the home at regular times. Equipment is regularly serviced and staff receive mandatory training so the risk of injury to people who use the service are minimised. EVIDENCE: The home has not had a registered manager in post since January 2007, this matter is being addressed separately from this report. Mr. and Mrs. Imonikhe said they are actively seeking to appoint another manager. An advertisement failed to produce anyone suitable for the post but another advertisement has been arranged and they hoped this time they would be able to appoint someone from the responses they receive. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 24 In the interim, Mrs. Imonikhe is managing the home as well as being the registered manager for their other home. She said she visits Canford Manor every day and staff can contact her by ringing Mr. Imonikhe who passes the message on. Staff said they did not always know when Mrs. Imonikhe was coming to the home and therefore they would not be able to tell people who use the service or relatives when she was available. The home uses survey forms to get feedback about the service they provide. Mrs. Imonikhe said she was developing one that specifically looked at the admission process so she could see if it was being managed as well as it could. The AQAA gave examples of changes made to practice following feedback by people who use the service. For example, changes to the menu had been made. It also stated that consideration was being given to the development plan for the service and that the AQAA would be used to review plans for improvement during the year. The AQAA was returned after the date it was required. It gave brief information about the service with limited evidence to support the statements made. It did identify what improvements the providers planned to make, such as developing person centred care plans and introducing more user-friendly survey forms. The AQAA recorded that people who use the service are encouraged to manage their own financial affairs. Mrs. Imonikhe stated that the home does not hold any money on behalf of people who use the service. If people cannot pay directly for services such as hairdressing, Mrs. Imonikhe pays it and invoices the family. It was noted that the upstairs bedroom windows are of a type that can be pushed open from the bottom. No window restrictors are fitted. Mr. Imonikhe said a risk assessment is completed to make sure the person in the room is not at risk. A temporary lock can be fitted if a risk is identified. However, people do not lock their bedroom doors and it is possible that someone could enter a room that is not theirs. Mr. Imonikhe was advised to contact the Health and Safety officer for guidance to make sure the home complies with Health and Safety legislation. The AQAA stated that staff received mandatory training such as moving and handling, infection control, first aid and food hygiene. Certificates were seen on staff files to evidence this and further training had been arranged. Fire safety training had recently been held and certificates to evidence this were seen. The AQAA recorded the dates equipment had been serviced. A random selection of these certificates were seen which evidenced the information given in the AQAA was correct. Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 25 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 26 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. Refer to Standard Good Practice Recommendations Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Canford Manor Nursing Home DS0000011493.V363372.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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