Inspection on 03/12/07 for Little Manor Nursing Home

This inspection was carried out on 3rd December 2007.

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

Little Manor Nursing Home 24/07/06

Little Manor Nursing Home 23/11/05

Little Manor Nursing Home 09/06/05

Little Manor Nursing Home 13/01/05

Little Manor Nursing Home 12/07/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Little Manor Nursing Home Manor Farm Road Salisbury Wiltshire SP1 2RS Lead Inspector Susie Stratton Key Unannounced Inspection 09:50 3 & 7th December 2007 rd 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 Little Manor Nursing Home DS0000047880.V355365.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. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Manor Nursing Home Address Manor Farm Road Salisbury Wiltshire SP1 2RS 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) 01722 333114 01722 337347 wessexcarepp@hotmail.co.uk Wessex Care Ltd Asha Tonse Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users who may be accommodated at any one time is 26 Only the one, named service user in the application dated 20/03/06 currently in residence in the home may be under 65 years of age. The staffing levels set out in the Notice of decision dated 20th July 2004 must be met at all times. 24th July 2006 Date of last inspection Brief Description of the Service: Little Manor Nursing Home is a large town house, which has been converted for use as a care home. The home is situated approximately a mile from the centre of the city of Salisbury, Wiltshire. The home is registered to provide nursing care for 26 older people. Little Manor has been extended several times. Accommodation is provided over a range of floors, connected by a passenger lift. There are two double rooms and the rest are single. Most rooms vary in shape and size. The front of the building is an older property, this has been extended and a bungalow incorporated to the rear. The bungalow is fully assessable from the main building and there is a separate entrance through the garden, for disabled people. Little Manor offers a homely environment for people to live in. The home provides two sitting/dining rooms, one in each part of the home with wheelchair accessible garden areas outside. The home is owned by Wessex Care Ltd. The Registered Manager of the home is Asha Tonse, who is a registered nurse. She is supported by registered nurses, care assistants, activities and ancillary staff. Wessex Healthcare provides central services for administration and maintenance. Fees range from £360 per week for residential care in a shared double room to £800 per week for nursing care in a double room used as a single room. Additional charges are made for hairdressing, newspapers, chiropody, toiletries, taxis and escort charges. All prospective residents or their supporters are given a copy of the service users’ guide. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included visits to the service and takes into account the views and experiences of people using the service. As part of the inspection, questionnaires were sent out to residents and their relatives and ten were returned. Comments made by people in questionnaires and to us during the inspection process have been included when drawing up the report. The home’s file was reviewed and information provided since the previous inspection was considered. A detailed annual quality assurance assessment was submitted by the home prior to this inspection. This document provided information to support the inspection. The site visits took place over two days, on Monday 3rd December 2007 between 9:50am and 3:35pm and on Friday 7th December 2007 between 10:00am and 1:30pm. The registered manager, Ms Asha Tonse was on duty on both days. Both the owners of the home and their service manager, who is a senior nurse, were present for feedback at the end of the inspection, as well as Ms Tonse. During the site visits, we met with eight residents, one visitor and observed care for nine residents for whom communication was difficult. We reviewed care provision and documentation in detail for five residents, one of whom had been admitted recently. As well as meeting with residents, we met with a registered nurse, two carers, the activities coordinator, the chef, a kitchen assistant and the human resources manager. We toured all the building and observed a lunch-time meal. We observed systems for administration of medicines and a medicines round. A range of records were reviewed, including staff training records, staff employment records, maintenance records and financial records. What the service does well: Wessex Care Ltd has a history of investing in their properties. They have progressively improved Little Manor, preserving its homely style, but ensuring that it is also functional as a modern nursing home. Staff spoken with were motivated; one who had worked in the home before the current owners bought it reported on how much improved the home was now that it was under the current management. Another newly appointed care assistant reported on how the owners had supported them when they commenced their employment. Staff all commented favourably on the supports for training and development provided. The owners have a clear system for reviewing quality of care provision and provision of facilities and equipment. For example, an action plan had been developed to improve arrangements for the storage of Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 6 medication. The annual quality audit, which was submitted as part of this inspection, was completed in depth and considered a range of matters. Staff have the skills to care for people admitted with complex nursing needs. For example for one person who was admitted with multiple pressure ulcers, some ulcers had already healed and others were responding well to treatment. Residents and their supporters commented on the quality of care, one reported “I can truly say that I have never regretted my choice” [in being admitted to Little Manor], another “It is nice” and another “I like it here, oh yes I like it here”. Several people commented on the staff, one reported “The girls are very good and I can talk to Matron easily”, another “Someone always comes when the buzzer is rung” and another reported that if they had a problem “I talk to Asha [the registered manager] and she sorts it”. What has improved since the last inspection? What they could do better: Three requirements and twenty good practice recommendations were identified at this inspection. Where a resident’s care plan indicates that they need to have their position changed regularly or be offered regular fluids, there must be evidence that this takes place, in accordance with directives in their care plan. Fluid charts should always be totalled every 24 hours and records of care given should state what care has been given, not just that staff have attended. Where residents are prescribed or choose to use topical applications, all care plans should document where the application is to be used and any other information relating to the application. Records relating to diabetic people should be precise and measurable, so that all staff will be aware, on all occasions of how their medical care is to be managed. Where a resident has a small wound, there should be documentation made relating to this, as they do for larger wounds. Where a resident has different specifications of pressure relieving equipment provided on their chair from on their bed, the reasons for this should always be documented. Where a resident has a urinary catheter in place, their records should always state the clinical indicator for the catheter. Where a resident needs the use of a restraint such as safety rails or a lap belt, a written assessment of need must always take place. This assessment must be regularly reviewed. Assessment documentation relating to the use of safety Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 7 rails and lap belts should conform to guidelines from the Health and Safety Executive. All pressure relieving mattresses should be regularly checked to ensure that the regulator is correctly set for the resident’s individual needs. Where residents share a room, systems must be in place to prevent communal use of wash bowls. A review of equipment such as pressure relieving cushions and safety rail protectors should take place and any which no longer have intact surfaces be replaced, to ensure that they can be fully cleaned. Chalk menu boards should always be up-to-date. Where a resident is prescribed a variable dose of a drug, the amount given should always be documented. If a resident is prescribed a drug which can affect their daily living, such as an aperient, pain killer or mood-altering drug, a care plan should always be drawn up, so that the effectiveness of the treatment can be assessed. Where a resident wishes to partially self-medicate, a risk assessment should always be drawn up. The medicines policy should be expanded to include administration of medicines by injection, via PEG feeding systems and self administration of medicines. If the home are crushing a tablet, there should be evidence that the pharmacist’s advice has been sought. The policy on safeguarding adults should be reviewed, to clarify what is meant by a “serious” matter, what the role of the police is and the local safeguarding adults’ procedure. Night staffing levels should be reviewed to ensure that the care needs of the service users are met by the staffing level provided. This was recommended at the previous inspection and has not been addressed. Staff training records should always be kept up-to-date. The manager should delegate the drawing up and evaluation of care plans to appropriate senior staff, to ensure that she is in a position to perform regular audit of care plans. 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. Little Manor Nursing Home DS0000047880.V355365.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 Little Manor Nursing Home DS0000047880.V355365.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): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents and their supporters are informed about service offered prior to admission, and have a full assessment of need, so that they can be assured that the home can meet their individual nursing and care needs. EVIDENCE: Residents and their supporters are given information about the home prior to admission. The information is professional in appearance and is attractively laid out. The information did not initially include the summary of the most recent report, a full copy of the report was available in the entrance hall. Service users’ guides given to residents or their supporters need to include a copy of the summary of the inspection report and information on how the full report may be obtained, to ensure that all prospective residents and their supporters are made fully aware of how the home is meeting it’s obligations under the Care Standards Act 2000. This was rectified during the inspection. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 10 All residents have a full assessment of need, prior to admission. These assessments are performed by a senior member of the management team who is a registered nurse. The registered manager is not involved in these assessments, although she reported that she would be able to discuss if her home could meet the prospective resident’s needs with the senior manager performing the assessment, prior to admission and that her opinion would be listened to. Assessments seen were completed in depth and included a range of matters relating to the individual’s nursing and care needs. These assessments provided a good basis for the development of care plans to meet individual’s needs. Care staff spoken with reported that they were fully informed of prospective resident’s needs and were able to prepare the person’s room prior to admission. The service user’s guide identifies that managers understand that admission to a care home is a complex and difficult time for individuals and their supporters. Their annual quality audit also indicates that the managers are keen to improve and develop areas relating to information for residents and their supporters prior to admission and further improve their admissions process. Of the nine people who completed this section of the questionnaire, all reported that they had had enough information about the home before they were admitted. We met with one newly admitted resident during the inspection and reviewed their records. The resident had limited communication skills, so was not able to comment directly on the admission process. Staff showed an awareness of how the resident had chosen to live their life previously. A relative of a different resident commented in their questionnaire “I had a list of nursing homes from the hospital. I came to see LM and was shown around by the matron, when I decided this was where I would like [my relative] to be I saw [a senior manager] and all arrangements were then made and [my relative] was moved in very quickly.” Little Manor Nursing Home DS0000047880.V355365.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents’ health and personal care needs are met. Some areas relating to evidencing compliance with care plans and evaluation of the use of certain equipment will further improve service delivery. EVIDENCE: All residents have care plans relating to meeting their individual needs. In their annual quality review, the home reported that they have recently reviewed their documentation, to reflect a more person centred approach. Where a resident has an assessed risk, such as pressure damage or manual handling needs care plans are developed to direct staff on how individual needs are to be met. Other risks are also considered, for example some residents are not able to use the call bell system and where this is the case, a risk assessment was drawn up. Discussions with care staff indicated that they are informed of individual resident’s needs at report, which they attend every shift and by reviewing care plans. One resident commented “The staff meet my Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 12 needs” and a relative reported “[My relative] is always well looked after and clean and fresh whatever time I visit. I feel this says a great deal about the high standard of nursing care and kindness […] receives.” Most care plans were clear and written in precise language, which directed staff on how to meet the person’s needs. Care plans were also highly individualised. For example one person had a very clear care plan to direct staff on how their personal care needs were to be met, including details such as preference for the sex of the carer and how they liked to be clothed during the day. Care plans relating to mobility were clear and directed staff on the use of aids to support someone in mobilising. If a person had continence care needs, care plans directed staff on the type(s) of continence pads to be worn. If a person needed thickening agent to assist them in swallowing, there were clear care plans, which were observed to be complied with in practice by staff. Where a person’s condition had changed, there was evidence that their care plan had been reviewed and up-dated to reflect their current needs. Some people had been prescribed or chose to use topical applications, some care plans stated which application was needed and where it was to be applied, but others did not and it is advisable that all care plans include such matters relating to individual treatment and care. Many of the residents in Little Manor were frail and had charts in place to ensure that their positions were changed and that they were offered fluids regularly. Reviews showed that staff were offering a range of fluids regularly, however fluid intake was not totalled every 24 hours as is advised, so that persons at risk of dehydration can be identified and appropriate action taken to meet the person’s needs. Records of care given to residents did not always document the care given and words such as “checked” or “repositioned” were used. If a person is assessed as being at risk of pressure damage, the actual care given needs to be documented, so that relevant staff can be informed of what position the person had been placed in, so that they are not put at risk of pressure damage by being left in the same position for an extended period. Care plans stated how often people needed to have their positions changed, in accordance with their assessed degree of risk of pressure damage. A review of charts did not provide evidence that the home were changing the persons’ positions at the frequency directed in their care plans. This particularly related to night shifts, where there are only two persons on duty. If people at risk of pressure damage do not have their positions changed regularly, there is a risk that they may go on to develop pressure damage. Such damage will much affect their well-being. Residents who were assessed as being at risk of pressure damage were provided with air mattresses on their beds and this was documented. Most resident’s air mattress regulators were set at a level which reflected their weight, however this was not the case for all regulators. As incorrect pressures on motors of air mattresses can increase the risk of pressure damage, regular checks need to be made on the settings of air mattress Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 13 regulators. Residents who were assessed as being at high risk of pressure damage were generally not provided with air cushions when sitting out and were provided with a lower specification chair cushion. For some residents, this may have related to the limited time that they spent out of bed, however this was not documented in their care plan. For other residents who spent longer out of bed during the day, as the degree of risk is not reduced when sitting out of bed, it was not clear why they were not provided with pressure relieving equipment of the same specification as provided on their bed. The home cares for several residents who have complex needs. One person had been admitted with multiple pressure ulcers. Records showed that the home had effectively managed nursing care relating to this person’s pressure ulcers and that all had responded to treatment and that some were now healed. Another resident had recently had surgical intervention on an area, which now needed dressings. Records showed that the home had effective systems to ensure that the area was correctly dressed and the wound’s response to treatment could be assessed. Where a resident had sustained minor tissue damage, the home did not always document what the damage was or how it was to be managed. One resident was noted to have a small dressing, they were not able to fully inform us of why they needed this dressing and there were no records in the person’s notes as to why the dressing was indicated. The manager was able to inform us of the reasons for the dressing. One resident experienced epileptic seizures. This person had a clear care plan relating to management of their seizures and a detailed monitoring record. Where a person felt unwell, staff made checks on their condition. For example during the inspection one of the residents reported to us that they felt faint. We reported this to the nurse in charge who checked the person’s pulse and blood pressure, to ensure that it was within normal limits and made a clear record. One resident needed a urinary catheter. There were full records as required relating to the type of catheter and changes of catheter, however their records did not document the clinical indicator for its use. This is advised as urinary catheters in the elderly are regarded as a risk to infection and should only be used if they are in the best interests of the person. One person was an insulin dependant diabetic. They had clear, measurable records in relation to their response to treatment, however their care plan could have been improved by more precision. Care plans for persons with diabetes should state the levels where a person is considered to have too high or low blood sugars and actions required by the home when this occurs. Where residents had additional mental health care needs, there were clear care plans relating to meeting such needs, these were written in non-judgemental language. We observed that many of the residents has safety rails on their beds. All people had a bed rail assessment in their records. Some records had not been completed in full and some had not been dated or signed. The standard assessment document did not conform in full to advice from the Heath and Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 14 Safety Executive, who regard bed rails as a form of restraint and report that numerous incidents have been reported relating to the use of these forms of restraint. None of the risk assessments had been reviewed regularly to assess if the restraint was still indicated. Where a resident needs a restraint such as safety rails or a lap belt, a full risk assessment must always be drawn up, this must be reviewed regularly, to assess if the restraint continues to be indicated. The home has safe systems for administration of medicines, with clear records of medicines received into the home, administered to residents and disposed of from the home. A medicines round was observed and we noted that the registered nurse performed the round correctly, ensuring that medicines record was checked and that medicines were administered individually. Some residents were prescribed a variable dose of a drug. A review of the medicines administration record showed that staff did not always document the actual dose given and this is indicated, so that all relevant persons can be fully informed. One person was partially self-medicating one of their tablets. This is seen as good practice. However a risk assessment had not been drawn up about this and this is indicated so that the safety of all residents can be considered. One resident was having tablets crushed. The written consent of the person’s GP and relative had been sought about this practice. As the effect of some tablets can be altered when crushed, the advice of the pharmacist should also be sought, as they are the professional who will know such factors. Some rooms do not have level floor access with the rest of the home. For these rooms, the registered nurse secures the trolley and takes medicines individually to the people in that area. The mangers reported that they had identified that this took up additional time and had plans in place to supply additional medicines storage in the bungalow area. Medicines were safely stored, however it was noted that the Controlled Medicines cupboard was very full. Again this had already been identified and a larger controlled medicines cupboard was reported to be on order. The home’s service user’s guide makes it clear that residents can self-medicate if indicated. The home’s medicines policy also does not outline procedures for administering medicines by injection, particularly insulin or influenza vaccination and this is indicated. Additionally as residents may be admitted who are PEG fed, policies on administration of medicines via PEG feeding systems in advisable. Where a resident is prescribed a medication which may affect their daily lives, such as mood altering drugs, aperients or painkillers, some people had care plans relating to this, but others did not. Some of the care plans stated some of the drugs used but not others. It is advisable that where drugs which may affect activities of daily living are used that these be clearly referred to in care plans, so that monitoring of their effectiveness for the individual can be fully assessed. Frail people who were cared for in bed looked comfortable, with brushed hair and clean night clothes and bed linen. Staff noted signs of distress promptly. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 15 For example, we noted after lunch that one person started showing signs of noisy behaviours. A member of staff promptly noted this, went to the resident, talked quietly and gently with them and made them comfortable, not rushing them and staying with them until the signs of distress were over. Several people commented on the attentiveness of staff, one reported “If I ring, they come straight away” and another “They are helpful when they come.” Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 16 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 visits to this service. Residents are supported in choosing to continue with the daily life and activities which they prefer. EVIDENCE: In their annual quality audit the managers reported that the coordinator’s hours had been increased from 15 to 30 hours a week. This person is able to work flexibly. An activities programme is displayed in the front hall. This shows a range of activities from large group, small group and individual activities. On the morning of the inspection, the activities person was performing 1:1 activities for people who did not want to or were not able to come out of their rooms. Five of the nine people who completed this section of the questionnaire commented that there were always activities provided by the home which they could take part in. Those who felt that this was not the case qualified it by reporting that they did not wish or were too unwell to take part in activities. One relative reported that they appreciated how the home tried to include their relatives in activities and another that their relative could not be involved in activities but that they were visited regularly by staff in their room. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 17 One resident commented on the singing and another on the games and another that there were people who they could chat to and that they enjoyed that. All residents have an assessment of their recreational needs and from this an individual care plan is developed. It was noted that records are added to as staff come to know more about the resident. The activities person reported that they had attended a training course to support them in their role. She reported that she found that many people particularly enjoyed music. For people who were very frail, she would sit and talk to them and she reported that many such people enjoyed hand massage. The activities person was aware of the importance of practice of religion to residents and was able to describe how residents who wished to were supported in their faith. The owners reported in their annual quality audit that they had come second in the “Wiltshire in Bloom” competition recently. People reported that their visitors could come when they wished. One person reported “There’s no restrictions on visiting”. Some residents go out of the home regularly with their visitors. Others are taken out on an individual basis by the activities person. One person regularly attends groups outside the home. Another person reported “I get a taxi into town and meet my family there.” As Little Manor is an older house, all the rooms are different from each other and of different sizes. This means that residents can make their rooms highly individual, if that is what they wish, to reflect their individual likes and preferences. Residents reported that they could choose how they lived their lives. One person said “I get up during the day, sometimes I go down to the lounge, I can choose what I do” another person reported about activities “I don’t always want to go but I’m always asked and encouraged”. Of the eight people who responded to this section of the questionnaire, two reported that they always and six, that they usually liked the meals. Comments varied from “I do not like the food” through “Meals are very different, sometimes alright, others not” to “The food is lovely”. Only one meal is displayed on the menu board in the main sitting dining room. In the smaller sitting dining room in the bungalow at the start of the inspection, the meal displayed related to the previous week, this was up-dated during the inspection but could be confusing to residents and their supporters. Discussions with residents showed that they were generally aware that they could choose to have something else if they did not like the main meal, one person reported “We have a varied choice”, another “If you don’t fancy something, they give you something else” however another person reported “There’s no choice of food.” The chef has been employed in the home for several years and showed an individual knowledge of residents’ likes and preferences. She was also aware Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 18 of special diets for residents. Many of the residents were too frail to come to either of the sitting/dining rooms for lunch where they were able to, a member of staff remained with them providing support when they needed it. Where residents ate in their rooms, meals were taken to them individually and were observed to be hot. Where residents needed assistance to eat, a member of staff sat with them, assisting them to eat, in an unhurried manner. Liquidised meals were attractively presented. Where a person needed artificial feeding, there were clear records of the nutrients given and evidence of contact with the dietician. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 19 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are protected by the home’s complaints procedure and procedures relating to safeguarding vulnerable adults. EVIDENCE: The home has a complaints procedure, which is displayed in the front hall and is available in the service users’ guide. The manager documents all complaints in a log. A review of this log shows that the home are conforming to their own policy and procedure on complaints. All of the ten people who responded to this section of the questionnaire reported that they knew how to make a complaint. One person reported “I talk to the staff, if they can’t sort me out, they find someone else who can”, another There is always a senior member of staff to talk things over with” and another “I talk to one of the girls if I’m not happy, if it’s more serious, I talk to one of the nurses.” Two complaints have been made to us about the service since the last inspection. Both were passed back to the owners for investigation and both were resolved locally. The home has a procedure on safeguarding adults. While this procedure includes most areas, it could benefit from some development, such as defining what “serious” incidents are and details of actions to take when matters need to be referred on. All staff spoken with reported that they had been trained in safeguarding adults, this was supported by records. The manager showed a Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 20 detailed knowledge of the procedure for reporting matters under the local safeguarding adults’ arrangements. A review of the file indicated that two matters have been reported since the last inspection. One was reported by the home in support of a vulnerable person and the other related to a need for action by an external agency, not the home. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 21 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, 20, 21, 22 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents are supported by a comfortable, homely environment which the owners keep well maintained and clean. EVIDENCE: Little Manor is a large town house which has been converted into a nursing home. Accommodation is provided on a range of different floor and levels with a passenger lift in between. As an older building, all rooms are different from each other and can be laid out to suit the individual’s preferences and needs. The owners have much invested in the building during the past few years and all parts of the home are nicely presented and well maintained. The atmosphere is homely and comfortable. The group of homes employs maintenance staff who work across all of the group. Staff reported a quick response when items needing attention were reported. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 22 At the time of the site visits, major works were taking place to the garden areas, to improve access for disabled people and wheelchair users. As part of the development, raised flower beds are being provided and a range of different small seating areas. When completed the garden areas will improve access for disabled people and greatly enhance the attractiveness of the gardens for residents to enjoy. The home has two sitting dining rooms. The larger of the two is in the older building towards the front of the house, it includes a conservatory-type dining area, which is light and looks over the gardens. At the rear of the building in the bungalow area of the home, there is a smaller sitting dining room, which also looks out over the garden. Some of the bathrooms have been upgraded and there are plans to improve all bathrooms. This is particularly needed for one bathroom where there were cracks in some of the grouting round the bath and some staining on the back of the bath hoist. Aids are provided to support people with disability. A range of hoists to meet different peoples’ disability, were noted on each floor of the home. All residents have manual handling care plans to direct staff on which aids are indicated to meet their needs. As noted in Standard 8 below, air mattresses are supplied to people assessed as being at high risk of pressure damage, but no air cushions were observed. The owner reported that they have a full supply of such aid in storage and that they can be made available to residents according to assessed need. All residents had been left with access to their call bells. Many residents had been provided with variable height beds, but not all. Some of the people who were cared for in divan beds had complex manual handling needs or swallowing difficulties. The manager reported that the owners were aware of this and were gradually supplying further variable height beds. This was confirmed by the owner, who has a planned programme for the supply of such beds. The home was clean throughout, with no dust or debris noted on high or low surfaces. The laundry area was maintained at high standards of cleanliness, including the areas behind the machines. It was reported that all infected and potentially infected items are always placed in appropriate bags to ensure they are washed separately. At present all other items of laundry are placed in the same bag and it is sorted in the laundry. This is not regarded as best practice, as sorting of laundry can present a risk of cross-infection and it is advisable that laundry is sorted at source to reduce this risk. In one double room, there were two wash bowls for the two residents. One of these had been named but the name had been washed out, the other was not named. Staff reported that wash bowls are regularly sterilised. To prevent communal use of wash bowls and risk of cross infection all wash bowls in double rooms need to be clearly labelled with the resident’s name. Some items of equipment such as bed rail bumpers and pressure relieving cushions had deteriorated surfaces and so would be difficult to wipe down to ensure cleanliness. A review of all such equipment needs to take place and any deteriorated items replaced, to ensure Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 23 that they can be fully cleaned. All staff reported that they had a ready supply of disposable gloves and aprons and were seen to use them. Registered nurses reported that they had good supply of sterile gloves and that they used them for all aseptic procedures. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 24 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 visits to this service. Residents’ needs are likely to be met by a staff team who have been effectively recruited, who are regular trained and are able meet residents’ different needs. EVIDENCE: The home has a registered nurse on duty for all shifts. She is supported by three care assistants during the morning and evening, two during the afternoon and one at night. Of the ten people who responded to this section of the questionnaire, 9 reported that they always and one that they usually received the care and support that they needed. The night shift commences at 8pm and completes at 8am. This means that for 12 hours there are only two people on duty to meet the needs of up to 26 residents. At the previous inspection, it was recommended that the night staffing levels be reviewed to ensure that the care needs of the residents can be met by the staffing level provided. The owners reported that the numbers of staff on night duty has been reviewed in the past. They were again asked to provide us with evidence that a review has taken place, this is particularly as noted in standard 7 above, because the home are not able to evidence that they are meeting directives in care plans relating to changes of position for people at risk of pressure damage. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 25 As well as nursing staff, the home employ a domestic, a chef and an activities person. A team of maintenance, administrative and managerial staff work across the group of homes. Turnover is fairly low and many of the staff have worked in the home for many years. The owners are supportive of training, including NVQ training. In their Annual Quality Audit, the owners report that they have been able to access NVQ training for people for whom English is not their first language during the past 12 months. All staff have an individual record of training undertaken, so that the manager can see at a glance the areas which have been covered and which need to be included. A review of records showed that while the manager held copies of certificates where staff have been trained, the individual training records have not been kept up to date. This makes training records complex to audit. All new staff have a full induction, which complies with current guidelines. Registered nurses are supported in undertaking training to meet resident’s needs. For example training in ear syringing for named registered nurses was being progressed at the time of the inspection. All matters relating to recruitment of new staff are dealt with centrally within Wessex Healthcare. No new registered nurses had been employed since the previous inspection. The files of two newly employed carers and a member of the ancillary staff were reviewed during the inspection. They showed that a full assessment of the person’s suitability for their role is carried out, including two references, a police check, a health check and review of their past work experience. All staff are assessed using an interview assessment record and any issues, such as gaps in employment records are probed at that time. All staff, including managers are given a contract and a job description. Staff are given a copy of relevant information when they commence employment and the home have a facility to translate information into a range of foreign languages for staff whose first language is not English. The files of three more long-standing staff members were reviewed and a few of them showed some gaps in information. The human recourses manager reported that she had only recently taken up her post as a full-time employee and was gradually going through all old staff files to ensure they conformed to current regulations. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 26 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, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents are supported by the home’s effective management systems EVIDENCE: The manager has worked in the home for several years, initially in a more junior position, she worked her way up to being deputy and when the previous manager left, she successfully became home manager. She is an experienced registered nurse and is currently undertaking the manager’s award. She has a clear job description to support her in her role. This job description outlines which are her areas of responsibility and which are dealt with centrally within Wessex Healthcare. There is currently a vacancy for a deputy manager. It was reported that this is being progressed within Wessex Care Ltd. At present the Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 27 manager is responsible for the drawing up of care plans for specific residents and it was discussed that, in order to ensure that she is able to fully audit all care plans, such duties should be delegated, to enable her to audit all care plans and ensure that all care plans are consistently completed (see Standard 7 above). Wessex Healthcare has full grievance and disciplinary procedures which records showed were complied with in practice. Wessex Care Ltd. has a system for reviewing quality of care; this is based on a range of outcome measures and is completed in detail. The views of residents and their supporters are regularly sought and there was evidence that actions were taken if matters identified. For example in their annual quality audit, it was reported that families had asked for more seating, so collapsible chairs are provided in a range of areas, which visitors can easily access. It was also reported that improvements had been made to the entry system so that visitors did not have to stand outside for periods of time in inclement weather while they waited for the door to be opened. The senior management team hold regular meetings where quality of care is an agenda item. These meetings are fully minuted, so that actions agreed can be reviewed. All issues relating to management of residents’ moneys are dealt with centrally. All residents have individual accounts and items such as hairdressing or chiropody are debited from their accounts. Residents’ supporters are invoiced monthly and there is a flexible system so that relatives can pay moneys in, in advance, if that is what suits them. All accounts are regularly audited. Where residents need cash, for example if they are going on an outing, this is easily sorted out and the cash is debited from their individual account. Where valuables are handed in for safekeeping, full records are maintained. Records show that all staff are regularly supervised. Supervision records were clear and individually completed. They showed that a range of matters relating to the individual and service provision were discussed. Training needs were clearly discussed during individual staff supervision. As the manager works on the floors, she is able to review staff performance on an individual basis. Records show that all staff are regularly trained in matters relating to health and safety, including manual handling, infection control and fire safety, in accordance with current guidelines. Staff were observed during the inspection and they were noted to conform to safe health and safety practice. All equipment was regularly maintained in accordance with manufacturers’ guidelines. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 28 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 29 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. Standard OP7 Regulation 17(1,a)S3 (3,k) Requirement Timescale for action 31/01/08 2. OP7 3. OP26 Where a service user’s care plan indicates that they need to have their position changed regularly or be offered regular fluids, there must be evidence that this takes place, in accordance with directives in their care plan. 13(1)(4,c) Where a service user needs the 31/01/08 use of a restraint such as safety rails or a lap belt, a written assessment of need must always take place. This assessment must be regularly reviewed. 13(3) Where service users share a 31/12/07 room, systems must be in place to prevent communal use of wash bowls. 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 Fluid charts should always be totalled every 24 hours. DS0000047880.V355365.R01.S.doc Version 5.2 Page 30 Little Manor Nursing Home 2. 3. OP7 OP7 4. 5. 6. OP8 OP8 OP8 7. 8. 9. 10. OP8 OP8 OP9 OP9 11. 12. 13. 14. 15. OP9 OP9 OP9 OP15 OP18 16. OP26 17 OP27 Records of care given should state what care has been given, not just that staff have attended. Where service users are prescribed or choose to use topical applications, all care plans should document where the application is to be used and any other information relating to the application. Records relating to diabetics should be precise and measurable, so that all staff will be aware, on all occasions of how their medical care is to be managed. Where a service user has a small wound, there should be documentation made relating to this. Where a service user has different specifications of pressure relieving equipment provided on their chair from on their bed, the reasons for this should always be documented. Where a service user has a urinary catheter in place, their records should always state the clinical indicator for the catheter. All pressure relieving mattresses should be regularly checked to ensure that the regulator is correctly set for the service user’s individual needs. Where a service user is prescribed a variable dose of a drug, the amount given should always be documented. Where a service user is prescribed a drug which can affect their daily living, such as an aperient, pain killer or moodaltering drug, a care plan should always be drawn up, so that the effectiveness of the treatment can be assessed. Where a service user wishes to partially self-medicate, a risk assessment should always be drawn up. The medicines policy should be expanded to include administration of medicines by injection and via PEG feeding systems. If the home are crushing a tablet, there should be evidence that the pharmacist’s advice has been sought. Chalk menu boards should always be up-to-date. The policy on safeguarding adults should be reviewed, to clarify what is meant by a “serious” matter, what the role of the police is and the local safeguarding adults’ procedure. A review of equipment such as pressure relieving cushions and safety rail protectors should take place and any which no longer have intact surfaces be replaced, to ensure that they can be fully cleaned. Night staffing levels should be reviewed to ensure that the care needs of the service users are met by the staffing level provided. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 31 18. 19. OP30 OP33 20. OP38 Not Addressed from the previous inspection. Staff training records should always be kept up-to-date. The manager should delegate the drawing up and evaluation of care plans to appropriate senior staff, to ensure that she is in a position to perform regular audit of care plans. Assessment documentation relating to the use of safety rails and lap belts should conform to guidelines from the Health and Safety Executive. Little Manor Nursing Home DS0000047880.V355365.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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