Inspection on 07/06/06 for Manley Court Nursing Home

This inspection was carried out on 7th June 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Manley Court Nursing Home 16/05/08

Manley Court Nursing Home 17/10/07

Manley Court Nursing Home 12/12/05

Manley Court Nursing Home 21/06/05

Manley Court Nursing Home 26/10/04

Manley Court Nursing Home 15/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Manley Court Nursing Home Manley Court John Williams` Close, Off Cold Blow Lane New Cross London SE14 5XA Lead Inspector Ornella Cavuoto Unannounced Inspection 07th June 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Manley Court Nursing Home DS0000006997.V298154.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. Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manley Court Nursing Home Address Manley Court John Williams` Close, Off Cold Blow Lane New Cross London SE14 5XA 020 7635 4600 020 7639 9433 phil.moon@manleycourt.ansplc.co.uk 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) ANS Homes Limited Mrs Philomena Mary Moon Care Home 85 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0), Physical disability (0), Physical disability over 65 years of age (0), Terminally ill (0), Terminally ill over 65 years of age (0) Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 49 older persons, of whom up to 6 may be terminally ill, and up to 14 may be 40 years old and above with chronic illness 36 persons with dementia, over the age of 55 years Date of last inspection 12th December 2005 Brief Description of the Service: Manley Court is a purpose built home providing care and nursing for up to 85 service users, of whom 36 may have dementia, 49 may be frail older people, of whom 6 may be in receipt of palliative care and 14 may be aged over 40 yrs of age and have a chronic illness. The private, nationwide company BUPA Care Services who took it over from Associated Nursing Services (ANS) in the past year owns the home. It is situated in a residential area of New Cross Gate. The nearest shops and railway station are ten minutes walk away. The nearest bus stop is several minutes walk away. The home was opened in 1996 and is on two floors. It is divided into five units of which two provide nursing care. There are two units for people with dementia and a small unit with rooms for people in need of palliative care nursing. All the bedrooms are single with en-suite facilities. There is a passenger lift. The home has two gardens at the rear that are accessible and secure. There is car parking at the front of the building. The home has a brochure and a service users guide that is made accessible to all prospective service users. Copies of CSCI reports are kept in the reception area and a copy is given to service users, relatives or a representative on request. The home’s fees range from £635 - £917 monthly. Additional charges may be made for hairdressing, toiletries, newspapers, outings, taxis and clothing. This information was provided to CSCI June 2006. Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two days. The registered manager and the Head of Nursing were both present and were involved in the inspection process. In addition, ten service users, three relatives, nine staff members and a professional visiting the home were spoken to. Other methods used included inspection of care records and a partial tour of the building. What the service does well: The majority of the service users spoken to were positive about the home and the care received from staff. One relative spoken to said with regards to their mother “She has done so well since she has been here. We are happy to know that they will care for her and that she has got protection here.” whilst another said, “ Staff are very kind and friendly. I feel I do not have to worry”. A service user who has lived at the home for some time expressed “ From the domestics to the management they are always there to help you” and another service user commented that the home was “Brilliant, everything the staff, the food just all over”. The home offers comprehensive support to service users using a variety of specialised services such as psychiatrists, nutrition specialists and speech therapists ensuring all presenting needs of service users are met. Service user care plans are reviewed on a regular basis and generally health care needs are well met. Staff ensure the privacy and dignity of service users is maintained. The home offers a good range of activities including regular exercise to keep service users stimulated and to ensure they are able to socially interact with others in and away from the home. Service users are supported to exercise choice and control over their own lives as much as possible. Service users are encouraged to maintain contact with relatives and friends with an open visiting policy in place. The home provides a varied menu that offers a choice of meals and specific preferences and cultural needs are catered for. The home ensures service users are well protected with an effective complaints policy and procedure in place that is accessible to service users and also by ensuring that all staff are trained and informed about adult abuse and by having effective policies and procedures in place around adult protection. The majority of the staff are trained to National Vocational Qualification (NVQ) Level 2 in care and others are being supported by the home to undertake the qualification. There is a comprehensive induction programme in place for those staff that commence working at the home. Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home needs to obtain a full needs assessment from the local/health authority to ensure the needs of service users admitted to the home can be fully met. Service users, relatives or a representative where appropriate need to be more involved in the care planning process and evidence this by signing the plan to acknowledge their agreement and understanding of its content. All records of assessments and care that is provided need to be consistently and thoroughly completed to make sure the health care needs of all service users are being fully met. Where pressure area care is to be provided and service users have a pressure sore this needs to be recorded in the care plan and reviewed regularly. Improvements around the recording of administration of medication need to be made. Staff need to receive instruction on how to assist service users with eating in an appropriate and sensitive manner. Service users with dementia and those that are bed bound need to be offered more activities that are appropriate to their needs. The home needs to continue with making efforts to keep the home free from all offensive odours. Staff working at the home need to be given more opportunity to attend training that will enable them to meet the specific needs of service users such as those with dementia more effectively. As part of the improvements the home has made around developing quality assurance systems and carrying out self- monitoring the home needs to draw up a development plan. All staff need to receive regular supervision. Manley Court Nursing Home DS0000006997.V298154.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. Manley Court Nursing Home DS0000006997.V298154.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 Manley Court Nursing Home DS0000006997.V298154.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 & 4 Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is in the process of issuing statements of terms and conditions to service users. Not all service users who move into the home have had their needs fully assessed. Service users know that the home will meet their needs. EVIDENCE: Subject to a previous requirement, there was evidence that the home is currently in the process of issuing service users with statements of terms and conditions and are trying to ensure they are all signed by service users, a relative or a representative where appropriate. Therefore, this continues to remain outstanding (See Requirements). Eight service user files were inspected four of which were for service users that had been admitted to the home since the last inspection. Of these, two files contained evidence that a full needs assessment carried out by the local authority or health authority had been obtained. However, for one service user only a brief nursing discharge summary had been obtained whilst for the other Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 10 service user there was no evidence on file that a copy of a full needs assessment had been acquired. It was reported that the home carries out their own assessment of service users needs prior to admission. Evidence of this was available on service user files. However, the home needs to ensure that a copy of the full needs assessment is also obtained to enable them to fully assess whether the home is able to meet the needs of those individuals admitted to the home (See Requirements). There was evidence to indicate that the home is able to meet the needs of service users living within the home. Specialised services are offered. The home has strong links with the local community mental health team and during the inspection a consultant psychiatrist and community psychiatric nurse visited the home to check and monitor service users needs particularly those with dementia. This occurs on a regular basis. The home also liaises closely with the Care Home Support Team (CHST), which includes an older person and a mental health specialist. Other specialist services used by the home include health professionals such as the tissue viability nurses and speech and language therapists, nutritionists and community palliative nurses. Furthermore although staff that work at the home do generally have the skills and experience individually and collectively to deliver the care and services that the home offers to provide more specific training needs to be made accessible to ensure that all the needs of service users can be met (See Details and Requirement relating to Standard 30). Manley Court Nursing Home DS0000006997.V298154.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 &11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans are generally comprehensive and although care plans are reviewed regularly they still do not always evidence the involvement of service users, relatives or a representative where appropriate in the care planning process. There are still inconsistencies in the recording of care provided to service users indicating that the health care needs for all service users are not always being fully met. The home has robust policies and procedures on medication but these are not always being adhered to by staff and therefore are not fully protecting service users. Service users feel they are treated with respect and their right to privacy is upheld. Service users have been consulted about their wishes for death and dying. EVIDENCE: Eight service user plans were inspected. The plans were generally comprehensive and in particular addressed the personal and health care needs of individual service users in good detail with some information specified around social care needs. All the plans contained a risk assessment that looked Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 12 at falls as well as other risks presented by individual needs of service users and appropriate measures to reduce identified risks were specified. There was evidence that care plans are reviewed monthly. The home has developed a care plan review form, which provides a summary of all the information contained in the care plan and also within the risk assessment. This addresses a previous requirement that risk assessments must be reviewed regularly. Changes in service user needs and circumstances are reflected in the care plan review forms. However, a previous requirement that the home must ensure these are signed by the service user, a relative or a representative where appropriate to indicate their involvement in the care planning and reviewing process has not been met. Of those care plan review forms inspected one had been signed by a service user (See Requirements). Subject to a previous requirement that the home must ensure that service users’ preferences are obtained in respect to how they would like their personal care carried out this has been met. Service user plans contained good detail about personal preferences. Also, service users spoken to were all satisfied with how staff supported them to address their personal care needs. In respect to meeting health care needs, generally care plans demonstrated that these were being met with evidence of close liaison with a range of health care professionals including nutritional specialists, psychiatrists and other mental health professionals, speech therapists and tissue viability nurses. It was also evident from care plans that service users have had access to opticians, dentists and chiropodists. In addition the home has an exercise assistant who ensures that those service users who may have difficulty mobilising are given an opportunity for an appropriate level of exercise. However, subject to a previous requirement there were still problems around inconsistencies in recording. The home carries out a number of assessments including those that look at nutrition, pressure area care, and incontinence amongst others. These are subsequently used to identify areas that need to be addressed within the care plan. At the last inspection it was identified that not all the assessments were being completed for all service users, potentially resulting in individual needs being overlooked. At this inspection, there had been a significant improvement in this area although it was still identified that specific assessments had not been completed, for example an incontinence assessment for a service user where this was a recognised problem. In addition, it was noted for another service user who is a diabetic that this had not been fully addressed within the care plan and blood sugar levels had not been consistently recorded on a monitoring chart (See Requirements). A previous requirement in respect to pressure area care has been partially met. At the last inspection pressure area turning charts indicated that service users with pressure sores were not being turned regularly enough. At this inspection one of the service users whose file was inspected had a pressure sore. The turning chart in place indicated that staff were regularly supporting Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 13 the service user to change their position four hourly. Also, pressure- relieving devices had been put in place, there was a wound care progress chart in situ, photographs had been taken and there was evidence of input from the tissue viability nurse. However, all this information had been placed in a separate file and it was not clearly evident from the care plan that the service user was receiving interventions in relation to pressure area care and that they had a pressure sore which was in need of being regularly reviewed. This needs to be addressed (See Requirements). The home has robust medication policies and procedures and only trained staff administer medication. Each unit of the home of which there are five has their own medication trolley and monthly audits of the medication for each unit are carried out. However, a previous requirement that all staff need to adhere consistently with medication procedures has not been met. A sample of Medication Administration Record (MAR) sheets was checked on three of the units. All the MAR sheets inspected were found to be accurate for two of the units. However, on one unit there were gaps where medication had been given and not signed for. Also, for one service user some of their medication could not be accounted for. There was a discrepancy in the amount of medication remaining against what had been signed for as having been administered and the number of tablets that had originally been entered on the MAR sheet. Only one unit had a controlled drug in stock for which recording and checks were accurate (See Requirements). All service users spoken to said that staff do treat them respectfully and maintain their rights to privacy and dignity. Care staff spoken to confirmed that the importance of maintaining service users privacy and dignity is addressed within their induction. Care staff were observed maintaining privacy whilst carrying out personal care and service users were seen to be generally well dressed and well groomed. There was evidence within service user plans that their personal wishes around death and dying had been addressed with them. The registered manager reported that the home is presently involved in the ‘ End of Life Gold Standard Framework’ which is a pilot scheme that aims to ensure that service users end of life is as comfortable as possible with all their needs being met and that there is involvement of service users, relatives and health professionals. Manley Court Nursing Home DS0000006997.V298154.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Although there are a range of different activities provided to service users both on an individual and group basis there needs to be more time spent with those service users who are less able. Service users are encouraged to maintain contact with family and friends. Service users are generally supported to exercise control and choice over their lives. Service users receive a varied and balanced diet but service users who need assistance are not always being provided this in an appropriate manner. EVIDENCE: The home has two activities co-ordinators one of which has worked at the home for the past two years whilst the other only recently started in post in the past couple of months. Both co-ordinators work Monday to Friday full time. As mentioned there is also an exercise assistant. The home did not have an up to date weekly activity schedule in place but records are maintained by each co-ordinator of the activities that are carried out with service users on a group and individual basis. Also, all activities are evaluated on a daily and monthly basis with service users that took part being listed and their level of participation noted. These records were looked at and it was evident that Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 15 service users are engaged in a range of activities such as art and crafts, playing board games, bingo, exercise to music, having video shows, massage and manicures. During the inspection, a number of service users from some of the units were gathered in the lounge on the ground floor for a video show and they were also involved in exercise to music with a balloon. Service users are also taken out to do personal shopping, the cinema and to eat out at restaurants. In terms of service users being engaged in activities a relative said with regards to their mother, “ She is very occupied in doing things which is important”. However, although it was clear that the majority of service users do receive a lot of stimulation, there was limited evidence of reminiscence sessions being held which is important for those service users suffering from dementia. The Head of Nursing reported they had recently completed a course in reminiscence and it is aimed that all service users will complete a life review form to gather more information about their backgrounds, interests and experiences. In addition, it was not clearly evident how the social care needs of those service users that are bed bound are being met and this also needs to be given consideration (See Recommendations). Visits from family and friends are very much encouraged by the home to ensure that service users maintain relationships of importance to them. Relatives and service users spoken to during the inspection confirmed that they are able to visit at any time and are always made to feel welcome. One service user said, “My family come in at least every other day and are made to feel welcome, given cups of tea and even my grandchildren are welcomed.” Service users confirmed that they are supported to exercise choice and control over their lives. A service user spoken to said with regards to the home and the staff, “They have never said to me no you can’t do that’. Service users can also bring in personal possessions and although rooms varied in terms of being personalised, there was evidence that some service users had brought in their own items of furniture and had photographs and other personal effects in their rooms. In addition, all service users had information in their rooms about the home including information about local advocacy services. One service user pointed out these are specifically for older persons and information regarding advocacy services appropriate for the needs of younger service users also needed to be obtained. Evidence that this had been obtained was sent to CSCI following the inspection. Feedback from service users about the food was largely positive. One service user said, “ The food is very good” whilst another commented, “The food is brilliant, you get a mixture but anything you want.” The home has a four weekly rolling menu that is changed in the summer. It offers a good variety of foods, specific cultural needs are catered for and a choice of meals is provided. At the last inspection, it was observed that a choice was not offered by one of the care staff to a service user who expressed that they did not like the dessert Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 16 offered and the inspector had to intervene. At this inspection, a breakfast and a lunch were observed and this did not occur. However, it was observed on two separate occasions that service users were assisted to eat by care staff standing up. Also, another service user who was given their breakfast in bed was not given a fork and began eating their food with their hands until the inspector had to become involved (See Requirements). Manley Court Nursing Home DS0000006997.V298154.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 inspected at least once during a 12 month period. 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 the service. Records of complaints investigations indicate they are taken seriously and are acted upon. Service users are protected from abuse. EVIDENCE: The home has a robust complaints policy and procedure. All service users are issued with an information pack that is placed in their rooms. This includes a copy of the home’s complaint policy and procedure and also as previously mentioned information about advocacy services. One relative stated that initial concerns had been acted upon very quickly and satisfactorily by the home. Service users spoken to said they have never had cause to make a complaint and the majority were aware of what action to take if necessary with some making reference to the fact that a copy of the policy was available to them in their rooms. The registered manager sends reports of all complaints received by the home to CSCI, which demonstrate that detailed investigations are always conducted and appropriate action is taken. Since the last inspection the home has had four complaints three of which were found to be substantiated and one unsubstantiated. In respect to adult protection the home has a robust policy and procedure. The whistle blowing policy is included in the staff handbook as well as an employee guide regarding the Protection of Vulnerable Adults (POVA) list to which Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 18 referrals of staff implicated in abuse of service users are made to prevent them from continuing to work with vulnerable adults. Employee responsibilities to report abuse are also addressed in the handbook. Both the registered manager and the Head of Nursing have completed courses to provide in house training around adult protection. It was reported by the registered manager that this training is completed with all staff as part of their induction. Discussion with care staff confirmed this. The home has had one adult protection investigation since the last inspection, which was found to be partially substantiated. Details of the investigation carried out by the home and a copy of the final report of the investigation carried out by the local authority were both received by CSCI. Manley Court Nursing Home DS0000006997.V298154.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users live in a safe environment that is generally well maintained but some repairs and renewals are still in need of being carried out. The home is generally clean and hygienic but there are ongoing problems with the management of unpleasant smells in the home. EVIDENCE: The home is purpose built and offers single en –suite accommodation with adequate personal and communal space. The home is divided into five separate units. There is a lounge and dining area on each unit and enclosed gardens at the rear of the premises. Overall the home is decorated and furnished appropriately. Subject to a previous requirement that areas of the home were in need of repair and items renewed this has been partially met. The carpet on the kitchen stairwell has been replaced with flooring that can be more easily cleaned. The crack on the stairwell by Hibiscus unit has been repaired and was found to be only superficial damage and the small kitchen on Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 20 Primrose unit has been refurbished. However, the carpet in the activities room, which was identified at the last inspection, as being badly stained has still not been replaced whilst at this inspection the carpet on the stairwell by Jasmine unit, was also identified as stained. As the registered manager reported this had been recently cleaned with no clear improvement it is evident this is also in need of being replaced (See Requirements). The home was generally clean and hygienic when the inspection took place. However, there were unpleasant smells noted on different units of the home in particular on Lavender and Primrose units. This has been an ongoing problem that the home continues to make efforts to address. It was noted on Lavender unit that a domestic was there at regular intervals during the inspection (See Requirements). The home has robust policies and procedures around infection control and staff receive training around infection control as part of their induction. Manley Court Nursing Home DS0000006997.V298154.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The numbers and skill mix of staff meet service users needs The home has exceeded the required number of staff to achieve a National Vocational Qualification (NVQ) Level 2 in care. Service users are protected by the home’s recruitment policy and practices Staff are trained and competent to do their jobs but care staff need to be given access to more specific training. EVIDENCE: Staffing levels have remained unchanged since previous inspections and are as follows: on Hibiscus, Lavender and Primrose units, there is one nurse and three care assistants on morning and afternoon shifts and one nurse and one care assistant at night. On Jasmine Unit there is one nurse and four care assistants in the morning, one nurse and three care assistants in the afternoon and one nurse and two care assistants at night. The palliative care unit has one nurse and one care assistant on both daytime shifts and one nurse at night. It was found at this inspection that staff numbers did correspond with those stated on all units apart from Lavender unit where a staff member had rung in to cancel their shift. However, cover was quickly obtained to ensure the unit was fully staffed. The home provided evidence that 58.6 of care staff have completed a NVQ Level 2 in care exceeding the required target that 50 of staff should have Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 22 attained the qualification. The home continues to support other care staff to undertake the NVQ Level 2. This was confirmed by care staff that were spoken to. Previous inspections have identified concerns around the home’s recruitment practices, for example at the last inspection an immediate requirement had to be issued as a result of staff being allowed to commence work prior to an Enhanced Criminal Record Bureau (ECRB) check having been obtained or a check being made against the POVA list. At this inspection seven staff files were checked and these were found all to be in order with all the required documents having been obtained prior to staff being allowed to start work. Under the new management of BUPA, the home has now got a new induction programme in place, which comprises of a booklet that incorporates Skills for Care specifications. There was evidence that new staff have either completed or are in the process of completing this. In addition, it was reported that all staff receive two days induction training when they start working at the home which involves them completing mandatory training including fire safety training, manual handling and adult abuse. They also complete food hygiene, infection control and health and safety training which is also mandatory and these are all regularly renewed as required. Staff records looked at provided evidence of this being completed. It was also reported that all care staff and qualified staff are in the process of undergoing Personal Best training which has been developed by BUPA and forms part of the appraisal process in that staff are required to complete a personal development plan as part of the training which is then looked at as part of an individual appraisal. However, although it was reported that the home has access to different training courses through BUPA and also the Care Homes Support Team (CHST) there was limited evidence that staff have completed training courses in areas such as dementia and managing challenging behaviour and mental health. It was reported that some of the qualified staff have undertaken courses in these areas but the home needs to ensure that all staff are given access to training that enables them to meet the specific needs of service users living at the home (See Requirements). Manley Court Nursing Home DS0000006997.V298154.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 at least once during a 12 month period. 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 a visit to the service. Service users live in a home that is well run and well managed. Although the home does have quality assurances systems in place a development plan needs to be drawn up. Service users finances are safe guarded. Not all staff receives regular supervision. Service users’ health, safety and welfare are protected. EVIDENCE: The registered manager is highly qualified and very experienced and regularly keeps her knowledge updated by attendance of a number of research committees and projects addressing areas such as Alzheimer’s, osteoporosis and mental health. The manager is also very keen to look at ways of helping the home improve and develop its practice in different areas and has involved Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 24 the home to partake in a number of different studies looking at MRSA infection control, incontinence and presently as mentioned ‘End of Life’. Overall, it is evident that she is very committed to her work and also has a ‘hands on approach’. A professional who visited the home during the inspection described how the manager “has an in depth knowledge of all the service users living in the home”. In terms of quality assurance BUPA has introduced a self - auditing tool that covers all the national minimum standards (NMS) although this has yet to be implemented. However, the home does currently have a number of systems in place to ensure quality of service is provided including carrying out monthly audits of care plans, medication, wound care and the environment amongst others. Monthly provider reports have been completed and there was evidence that a customer satisfaction survey was also completed last year in the autumn, the results of which were compiled into a detailed report meeting a previous requirement. However, a development plan based on the findings of that survey and which reflects aims and outcomes for service users was not completed (See Requirements). With respect to service user finances, the home is presently appointee for three service users although under BUPA the home is not to take on any further appointee ships. It also supports the majority of the service users living at the home to manage their personal allowance, which is presently paid into a non –interest bearing account. Detailed records of all payments and withdrawals relating to each service user with funds in the account are maintained and balances are given to service users after each transaction that also acts a receipt. The home is also aiming to produce a weekly statement. This is currently carried out every 28 days to ensure that all monies reconcile with transactions carried out over the month. In addition, money that builds up in the pooled account for individual service users is regularly transferred into service users own savings account or passed onto relatives to put into individual accounts to enable them to accrue interest on their savings. Staff supervision takes the form of both qualified and care staff having to produce a written article on an identified learning need, for example such as adult abuse or mouth care. They are to complete six articles in a year. However, records held by the home did not reflect this was occurring regularly for all staff (See Requirements). It was reported by the registered manager and deputy manager that support is also provided to staff on an ongoing basis around looking at their performance and giving them an opportunity to discuss any concerns they have about their work. The home has robust policies and procedures around health and safety. Also, as mentioned staff complete mandatory training that is regularly updated. Fire safety records evidenced that fire alarm call points are carried out weekly and regular fire drills have taken place at different times to ensure all staff are familiar with the process. Water checks have been completed. There were risk Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 25 assessments in place for the Control of Substances Hazardous to Health (COSHH). An up to date building and fire risk assessment was not available on the day of the inspection but copies of these were sent to CSCI shortly following the inspection. It was reported that maintenance checks for specialist equipment have been delayed in being carried out with a change of suppliers and contractors being introduced but copies of these were also sent to CSCI shortly following the inspection. Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 26 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 2 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5(1)(c) Requirement Timescale for action 30/11/06 2. OP3 14 (1) 3. OP7 15(1)&(2) The registered person must ensure that on moving into the home, each service user is provided with a statement of terms and conditions, that includes all of the information listed under Standard 2.2 of the National Minimum Standards and it is signed by the provider and the service user or their representative. (Previous timescales of 31/01/05 and 30/09/05 not met and timescale of 30/04/06 partially met) The registered person must 30/11/06 ensure that a full needs assessment is obtained from the local/health authority to ensure the home is able to fully meet the needs of service users admitted to the home. 30/11/06 The registered person must ensure that all service users and or a relative or a representative where appropriate are involved in the drawing up and reviewing of care plans and that this is indicated by a signature being obtained. (Previous timescales DS0000006997.V298154.R01.S.doc Version 5.2 Manley Court Nursing Home Page 28 4. OP8 12(1)(a)& 17(1)(a) 5. OP8 12(1)&(2) 6. OP9 13(2) 7. OP15 12(4)(a) of 30/09/05 and 30/06/06 not exceeded) The registered person must ensure that all records of assessments and care given are completed thoroughly and accurately as a measure to ensure health care needs are being fully met. These should include dates and staff signatures. (Previous timescale of 30/06/05, 30/09/05 not met and timescale of 30/06/06 partially met although not exceeded). The registered person must ensure that where service users are receiving care around pressure sores these are clearly addressed in individual care plans and this is reviewed on a monthly basis. (This is an updated requirement) The registered person must ensure that the systems in place for recording and monitoring the administration of medication are used consistently and effectively specifically staff sign the medication administration records for all medication administered, daily and in respect to handling medication that stocks of tablets correspond to that amount recorded on the MARS (Medication Administration Record) sheets. (This is an updated requirement. Previous timescale of 30/06/06 not exceeded) The registered person must ensure that staff are given proper instruction about how to assist service users to eat in an appropriate and sensitive DS0000006997.V298154.R01.S.doc 30/11/06 30/11/06 30/11/06 30/09/06 Manley Court Nursing Home Version 5.2 Page 29 8. OP19 23(2) (b)&(c) 9. OP26 16 (2) (k) 10. OP30 18 (1) (c) (i) 11. OP33 24 12. OP36 18 (2) manner. Also, that service users must always be given the appropriate utensils to enable them to eat their food appropriately. The registered person must ensure that repairs are carried out and renewals of items are purchased. This specifically includes: a) The carpet on the stairwell by Jasmine unit being replaced. b) The carpet in the activities room being replaced. (This is an updated requirement. Previous timescale of 31/08/06 not exceeded). The registered person must ensure that all areas of the home are kept free from offensive odours. (Previous timescale of 30/06/06 not exceeded) The registered person must ensure that staff receive training in areas that enable them to meet the needs of service users living at the home more effectively. The registered provider must ensure that following a customer satisfaction survey being carried out and the results analysed that an annual development plan should be produced that reflects aims and outcomes for service users. The registered person must ensure that all staff receive at least 6 supervision sessions annually. 31/08/06 31/08/06 31/01/07 31/01/07 30/11/06 Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 30 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. Refer to Standard OP12 OP12 Good Practice Recommendations The registered person must try to ensure that reminiscence sessions are held particularly to support those service users with dementia. The registered person must try to ensure that the activities co-ordinators spend regular time doing appropriate activities with those service users that are more bed bound. Manley Court Nursing Home DS0000006997.V298154.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. 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