Inspection on 14/06/05 for Crann Mor Nursing Home

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Crann Mor Nursing Home 13/09/07

Crann Mor Nursing Home 25/07/06

Crann Mor Nursing Home 26/09/05

Crann Mor Nursing Home 07/12/04

Crann Mor Nursing Home 02/07/04

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Crann Mor Nursing Home 151 Old Woking Road Pyrford Woking, Surrey GU22 8PD Lead Inspector Janet Daulton UnAnnounced 14 June 2005 14:00 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 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. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Crann Mor Address 151 Old Woking Road Pyrford Woking Surrey GU22 8PD 01932 344090 01932 344090 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr A M Emambux Mrs M Emambux CRH Care Home 24 Category(ies) of OP Old Age registration, with number of places Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service users may be admitted from age of 60 years onwards - Date Implemented 1 April 2002 Date of last inspection 7 December 2004 Brief Description of the Service: Crannmor is a large two storey detached property, which has been adapted to provide nursing care for up to 24 Older Persons. The home is situated in a residential area not far from the town of Woking. Accommodation is offered mainly in single rooms. There are communal areas consisting of a lounge/dining room and another small sitting area within the home. There are gardens to the front and rear of the property, and there is ample parking within the grounds. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4.5 hours and was the first inspection carried out by the Commission for Social care Inspection for the year 2005-2006. The inspection was carried out by Janet Daulton, Lead inspector for the service. The Registered person, and Manager, Mr. and Mrs Emamabux, were present for all of the inspection. A tour of the premises took place. Four care plans, the complaints log, staff recruitment files, and a sample of safety certificates were inspected. The inspector spoke to most of the service users, and 2 visitors. The inspector also spoke with some of the staff on duty at the time of the inspection. Overall this was a positive inspection. The inspector would like to thank the staff and service users for their time, assistance, and hospitality during the inspection. What the service does well: What has improved since the last inspection? Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 6 The home had carried out a service user survey and produced a report that was positive in its findings. The recruitment process protected the service users, and necessary checks were carried out before a member of staff was employed. 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. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4,6 Some service users were not provided with all the information about the home, in order for them to make an informed choice. Service users are assessed prior to entering the home to ensure that the home can meet the needs. EVIDENCE: The Service User Guide was evidenced at inspection. However one visitor spoken to said that she had not received a Service User Guide. The Manager informed the inspector that service users funded by Social Services are not given a Service User Guide. There were no details in the Service User Guide as to how the Commission for Social Care Inspection reports of the home could be obtained. A requirement was issued that all service users must receive a Service User Guide. Service user contracts were sampled which stated the terms and conditions of the home. All service users were assessed prior to admission, and service users have a trial period, to ensure that they were satisfied with the home, and whether the home was suitable for them. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 9 It was noted at inspection that several service users had a clinical diagnosis of dementia. The home is not currently registered for admitting service users with dementia. The Manager agreed to submit an application for variation to the Commission for Social Care Inspection for amendment of the Certificate of Registration. The home had the skills and experience to provide the necessary care for the service users who were accommodated at the time of the inspection. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10,11, Cree plans were seen to be comprehensive and clearly set out the care needs of the service users. Care was provided in a respectful and dignified manner. EVIDENCE: Care plans were randomly selected for inspection. All the care plans were detailed, with appropriate risk assessments. Care plans were signed by the service user. All records were kept up to date, and regular reviews of care plans were being made. The service users told the inspector that they enjoyed living in the home, and that their privacy was respected. Staff were observed to be caring for the service users in a friendly and professional way. The home had adequate equipment to manage moving and handling needs and pressure sore prevention needs. The home has a policy on the care of the service user who is dying. This policy stated that staff specifically trained in the care of the dying were available. The Manager was unable to confirm that this arrangement was in place. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 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 standard(s) 12,13,15 The home offered opportunities for the service users to choose their lifestyles, however the activity provision needs further development. Visits from relatives were encouraged. The catering facilities were satisfactory. EVIDENCE: The home had a visit every fortnight from an activities organiser, who played games with the service users, The range of activities available in the home was very limited. There was no programme displayed of regular activities provided. On the day of the inspection most of the service users were either sitting in the lounge or their bedrooms with the television on. Several of the service users in the lounge were asleep. There were no service users attending a church. A number of service users went out with their relatives. Two visitors were spoken with during the inspection, and they stated that they were always made to feel welcome, and were kept fully informed about their relative. Service users spoke well of the food served to them. The chef knew the service users likes and dislikes. From evidence gained at inspection the planned menu was not always being followed, and it was recommended to be kept up to date. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 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 standard(s) 16,18 Service users were given information about the complaints process, and were aware how they could complain if they were not happy. Staff had the necessary knowledge to deal effectively with prevention of abuse of adults. EVIDENCE: The complaints procedure was displayed in the home. Service users stated that they felt confident that any concerns would be fully addressed by the home. There have been no complaints since the last inspection. Staff demonstrated knowledge of the vulnerable adults process. There had been one vulnerable adults investigation under Surrey’s multi agency procedures. This had been dealt with appropriately by the management and the investigation closed. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 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 standard(s) 19,26 The home presented as a homely and comfortable environment with a good standard of cleanliness. Risks to the safety of the service users were identified at inspection, and action must be taken to ensure their safety EVIDENCE: The home was clean and furnished in a homely and comfortable way. A record was kept of decorating and maintenance. The grounds were untidy with old mattresses and old chairs. Some of the paving slabs on the patio area were uneven and could present a risk to the service users, and are required to be made safe. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29, The numbers and skill mix of staff met the service users needs. Service users were protected by good recruitment practices. EVIDENCE: The staff rota examined demonstrated that the staffing numbers and skill mix were appropriate to meet the assessed needs of the service users living at the home. Service users were very complimentary about the staff working at the home. Random samples of staff files were examined. All necessary checks had been completed prior to employment. Staff training files demonstrated that staff were adequately trained for the work that they do within the home. The home currently does not meet the standard of a minimum ratio of 50 members of staff achieving level 2 NVQ by the end of 2005. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,36,38 The home was being managed in the best interests of the service users. The home had an effective quality assurance system in place that was based on seeking the views of the service user. The registered person must address Health and safety issues to protect the service users. EVIDENCE: Staff and service users were complimentary about the management of the home. The Manager has not commenced the Registered Managers award, and is required to do so. Staff were receiving regular supervision, and records were maintained. A random examination of Health and safety training records and maintenance records was carried out. The last fire training update was recorded in 2003. All staff must have a yearly fire safety update. Fire bell testing was not being carried out weekly, but monthly, and is required to be tested weekly. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 16 Water temperatures at one bath were recorded at a higher level than recommended. This was actioned at the time of the inspection, and this must be checked regularly. The home did not have a general risk assessment in place, and the fire risk assessment was last completed in 2003 The home had carried out an internal service user survey, and a report has been compiled since the last inspection. This report was positive in its findings. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 x 3 x x 3 x 1 Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 18 no Are there any outstanding requirements from the last inspection? 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 OP1 OP1 OP4 Regulation 5(2) Requirement Timescale for action August 31st 2005 August 31st 2005 July 31st 2005.3 4. 5. 6. OP12 OP19 OP19 7. 8. 9. 10. OP28 OP31 OP33 OP33 The Service User Guide must be made available to all service users or their representative. 4(1) The Service User Guide must include details of how to obtain the inspection reports 12 The Registered person must Registrati make application to the on Commission for Social Care Regulation Inspection for a variation to the s. registration of the home. 16(2)(m)( The provision of a programme n) of varied stimulating activity needs further development 23(2) The old mattresses and chairs in the garden must be removed. 23(20(o) the registered person must complete a risk assessment for the patio area and take action if the uneven paving slabs pose a risk to service users 18(1) A minimum ratio of 50 of staff achieve level 2 NVQ or equivalent. by 2005 9(2) The Manager must obtain a relevant management qualification by 2005 23(4) Staff must have fire training 23(4) The Registered person must complete a fire risk assessment August 31st 2005 August 31st 2005 Aiugust 31st 2005 December 31st 2005 December 31st 2005 August 31st 2005 August 2005 Page 19 Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 11. OP33 13(4( water temperatures at baths must be at a safe recommended level 12. 13. OP33 23(4) Actioned at the time of the inspection. The registered person must carry Immediate out regular weekly testing of fire bells. 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. 2. 3. Refer to Standard OP11 OP15 OP33 Good Practice Recommendations Staff should receive specific training in the care of the dying person. There should be an accurate record of what meals are being served. A general risk assessment of the environment should be carried out. Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 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 Crann Mor Nursing Home H58 H09 s17602 Crann Mor v235534 140605 Stage 4.doc Version 1.40 Page 21 - 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. 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