Inspection on 03/07/07 for Manon House

This inspection was carried out on 3rd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manon House 24/07/06

Manon House 06/02/06

Manon House 17/10/05

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

CARE HOME ADULTS 18-65 Manon House 2 Carlton Road South Croydon Surrey CR2 0BP Lead Inspector Barry Khabbazi Key Unannounced Inspection 3rd July 2007 09:30 Manon House DS0000062856.V344697.R01.S.doc Version 5.2 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 Manon House DS0000062856.V344697.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 Adults 18-65. 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. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manon House Address 2 Carlton Road South Croydon Surrey CR2 0BP 020 8657 9202 020 8657 0313 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) Mr Chedumbrun Shunmoogum Mr Chedumbrun Shunmoogum Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th July 2006 Brief Description of the Service: Manon House 2 is situated in a residential area of Sanderstead. It is approximately one point five miles from Croydon Town Centre. Carlton Road is served by one bus that leads directly to the centre of Croydon. The home was recently registered in February 2005. The home is currently registered to provide accommodation and personal care to four younger adults with a mental health needs. The home offers four single rooms. There is a kitchen and dining area. There is also a communal lounge. Manon House is described by the owner(s) as being a Rehabilitation Unit where service user’s are supported and encouraged to develop/re-develop the necessary skills to move onto more independent living. The fees are currently range from £750 Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key Standards identified throughout this report were assessed at this inspection. This inspection also focused on following up on previous requirements and recommendations, and any new issues arising. This inspection was unannounced and started early in the day to allow the residents to be met, before they went to their day activities. During this inspection the acting manager was interviewed. Records, policies and care plans and the building were examined. The National Minimum Standards are almost all met at this home and areas exceeding the standards are recorded in this report. One minor requirement was needed at this inspection. Please see ‘what they could do better’ for details Only positive comments about the home were made by the residents placed. What the service does well: What has improved since the last inspection? What they could do better: Although water testing has now occurred and there are no identified problems, a risk assessment needs to be produced to identify the required frequency of future testing. This will protect residents from many infections for example legionella and e-coli. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 6 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. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2; Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users needs are assessed before they start at the home to ensure that all needs are known. EVIDENCE: The last inspection report recorded that all of the assessment documentation under Standard 2 was observed to be present in service users’ files. All files sampled contained assessments and care plans/ CPA’s {Care Programme Approach}. Standard 2 was assessed as met at that time. There had been no new service users since the last inspection. This standard could not therefore be re-assessed on this occasion and remains met. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, and, 9: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ assessed needs, changing needs and how the home meets these needs are now fully recorded. This supports the home’s ability to meet and show how it has met all a residents known needs. Service users make decisions about their lives with support where needed. The service users are generally well and safely supported to take risks as a part of independent living. EVIDENCE: Files and care plans were available for all service users. These were all regularly reviewed and updated. Reviews were occurring with the desired frequency. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 10 The last report recorded that ‘the new service users’ care plan did not reflect all the elements required under Standard 6.2. In particular, education and employment needs were not included.’ The following requirement was then set under Standard 6 to address this: A record of all of a service user’s needs to be met or supported by the home must be recorded in their plans of care. In particular educational and employment needs must be included. Files examined on this occasion had been updated to include all the elements required. This Standard and this requirement are now therfore met. The service users are offered the opportunity to participate in the day to day running of the home and to contribute to the development and review of policies and services through regular house meetings and individual discussions with their key workers. Risk is assessed prior to admission and continually updated. Risk assessments were available and had recently been updated to show what other options are explored before any restriction of liberty required for the protection of service users is implemented. Risk assessments have also now been completed for all existing restrictions of liberty required for the protection of service users. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 13, 15, 16, and 17. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity for self-development, are part of the local community and are able to take part in appropriate activities. Service users are well supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. The food provided is sufficient in quantity, and it is sufficiently nutritious. This is important to ensure good health. EVIDENCE: Service users either attend college, are employed or are in supported employment schemes. Service users access the community independently and engage in activities of their choice. Service users were observed accessing the community during this inspection. Information about local community resources is included in the induction to the home. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 12 Evidence of the home promoting appropriate relationships and providing service users with information and access to health professionals was provided during the inspection. Home visits are supported, visitors to the home are also supported up to 10pm. Visits can occur in private. Counselling is provided at the home by a qualified counsellor. Service users have access to education regarding numeracy and literacy where required. Spiritual needs are supported at this home. The daily routines do promote independence. All service users are offered keys to the front door and their rooms. There is a telephone, for use by service users, as confirmed by certain of the service users during the inspection. Service users can choose when to be alone or when to be in company. Independence skills are promoted as a part of the care plan where required. The setting up of a cooking rota and a household task rota encourages the promotion of independence within the home. Tasks are rotated to ensure fairness of allocation. Staff are available to offer support as necessary. The level of support offered is geared to meet the individually assessed needs of each service user. The service users are supported to buy and cook their own food on an individual basis. Where required support from dieticians was seen to have been sought by the home. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal support needs and emotional health needs are met well by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is also well managed to ensure maximised good health. EVIDENCE: Personal care is not provided by the home or required by the service users. All the service users met were content with the support received from staff. The Registered Manager has an arrangement with each service user to meet individually once per week. The aim of this meeting is to provide the service user with a chance to talk if they wish to. This meeting is in addition to a Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 14 weekly key worker meeting, or any other meetings with their CPA Coordinator, CPN or care manager. Counselling is provided at the home by a qualified counsellor. Access to health services was seen to be supported in files sampled. Inspection of the service users files confirmed that all are registered with a G.P. and all have been supported to gain access to NHS resources as required. Regular health checks are also offered and specific referrals are made as and when identified as needed. Most service users self medicate. Medication records were examined and found to be clearly and regularly recorded. A British National Formulary is available for guidance for staff. All staff who administer medication have had accredited training and additional in-house training. Consent to medication was recorded on files sampled. Facilities to store medication safely are available at the home. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well so that service users usually feel their views are listened to. The home’s policies and procedures relevant to this Standard facilitate protecting residents from abuse, neglect and self harm. EVIDENCE: The home has a complaints procedure in place, which clearly states how complaints will be investigated, recorded and redressed. This procedure contained all the elements required under Standard 22, including a 28 day response time and details of how to contact the Commission. Records are kept of all complaints. Service users also have the opportunity to raise issues directly with staff individually or in group meetings, before they develop into a complaint. Service users met at this inspection said they were happy at the home. A restraints policy, an adult protection policy, a physical and verbal aggression policy, a whistle blowing policy, an access to files policy, and a gifts and wills policy. All the above policies were present and known to staff. There have been no adult protection concerns raised regarding this home. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, and 30: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is homely, comfortable and safe and the environment does promote the residents well being. Bedrooms either meet or exceed the minimum bedroom size standard. Communal areas exceed the minimum communal area size standard. Both these provide additional space for the residents. The home is hygienic and clean. This environment therefore facilitates the residents’ health and emotional well-being. EVIDENCE: Manon House 2 is situated in a residential area of Sanderstead. It is approximately one point five miles from Croydon Town Centre. Carlton Road is served by one bus that leads directly to the centre of Croydon. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 17 The home is currently registered to provide accommodation and personal care to four younger adults with a mental health needs. The home offers four single rooms. There is a kitchen and dining area. There is also a communal lounge. Bedrooms either meet or exceed the minimum bedroom size standard. Communal areas exceed the minimum communal area size standard. Residents’ rooms were individually decorated and rooms had been individualised by the residents. The kitchen and smoking area were the areas frequented by the service users on this visit, as opposed to the main lounge. Others opted to spend time relaxing in their rooms. Most of the service users go out early in the morning. The home’s premises are accessible to the current service user group, in keeping with the local community, and are suitable for their purpose. The premises were clean, and well maintained. There was suitable domestic lighting and ventilation. At the time of the inspection the premises were well furnished and in an appropriate style. The building was observed to be clean and tidy. The home gave the impression of a clean home. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are supported by suitably qualified staff. The home’s recruitment procedures protect the residents through vigorous staff vetting. Induction and foundation training programme are within Sector Skills Council training specifications and timescales. This facilitates the staffs’ ability to meet all a resident’s needs and raises the quality of staff and their practices. Staff are well supervised to ensure that they receive appropriate training and perform in a manner conducive to the service users’ well being. EVIDENCE: The following good practice was identified: Agency staff are not used which facilitates continuity of staff. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 19 The home is continuing to support staff with accessing NVQ training. It has the 50 of staff with a NVQ2 required under Standard 32. This home has an Equal Opportunities Recruitment Policy. There have been no new staff employed since all the staff files were last inspected. There was therefore no need to re- examine staff recruitment files at this time. The last report recorded that all staff files contained all the elements required, including Criminal Record Bureau checks, two written references, a photo, copies of two forms of identification, and the application form. There had been no incidents requiring staff to be referred to the Protection of Vulnerable Adults register. Induction and foundation training programme are within Sector Skills Council training specifications and timescales. Staff supervision records were sampled. These showed that supervision had exceeded the 6 per year frequency required under Standard 36 by almost double. The supervision pro-forma provides for a structured supervision session. Both the supervisor and supervisee sign the record of supervision. In addition to normal staff supervision records, additional brief supervision sessions also occur and are recorded. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, and 42: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. There is a quality assurance system which involves the service users and provides a way for them to measure improvements in quality for themselves. The health and safety, and welfare of the residents is generally well promoted and protected. EVIDENCE: The Registered Manager has the Registered Manager’s Award. This combines the Certificate in Management Studies and the NVQ Level 4. The Registered Manager previously owned/managed a 14-bedded care home for the elderly. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 21 There is a quality assurance system, which involves service users. The quality assurance tools include, service user questionnaires, the complaints system, service user meetings, one to one discussions, and inspections. Where appropriate information from the above sources are included in the annual development plan. This is then made open to the service users through residents meetings, to allow measurement of achievement in improving quality. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all included in staff induction. Control Of Substances Hazardous to Health policies were observed and these substances were all locked away. Risk assessments covering safe working practices were present and these included individual resident and environment specific risk assessments. All of the procedures and testing of systems required in Standard 42 were also present, including the record of regular tank testing and system cleaning to control the risks of Legionella. As the next water testing certificate will be due soon the manager questioned the required frequency of these tests in regards to the risk at the home. It was agreed that a risk assessment would be undertaken to facilitate assessment of the required frequency. The following requirement is set to facilitate this: The manager must produce a risk assessment to identify the required frequency of future water testing in relation to the size, usage and age of the water systems. As this does not present a current risk the minor shortfall here will not transfer to the rating whole group of management standards. Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 23 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 YA42 Regulation 13(3)4 Requirement The manager must produce a risk assessment to identify the required frequency of future water testing in relation to the size, usage and age of the water systems. Timescale for action 01/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Manon House DS0000062856.V344697.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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