Inspection on 06/02/06 for Manon House

This inspection was carried out on 6th February 2006.

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

Manon House 02/07/07

Manon House 24/07/06

Manon House 17/10/05

Manon House 16/11/04

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

CARE HOME ADULTS 18-65 Manon House 82 Mayfield Road Sanderstead Surrey CR2 0BF Lead Inspector Barry Khabbazi Unannounced Inspection 6th February 2006 9:30am Manon House DS0000028584.V282358.R01.S.doc Version 5.1 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 DS0000028584.V282358.R01.S.doc Version 5.1 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 DS0000028584.V282358.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Manon House Address 82 Mayfield Road Sanderstead Surrey CR2 0BF 020 8657 9202 020 8657 0313 kishnama@hotmail.com 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) Mrs Kishnama Shunmoogum Mrs Kishnama Shunmoogum Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: Manon House is situated in a residential area of Sanderstead. It is approximately one point five miles from Croydon Town Centre. Mayfield Road is served by one bus that leads directly to the centre of Croydon. The home is currently registered to provide accommodation and personal care to five younger adults with a mental health issue. The home offers five single rooms. The kitchen and dining area link directly onto the second lounge that serves as a smoking area for those service users that smoke. There is also a communal lounge. Manon House is described by the owner(s) as being a Rehabilitation Unit where service users are supported and encouraged to develop/re-develop the necessary skills to move on to more independent living. Two care staff are on shift during the day time hours. At night one of the owners undertake a sleepin shift at the home. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key Standards identified throughout this report were all assessed at the last inspection, which was the main inspection for the year. Please see that inspection report for a full audit of all the key Standards. This unannounced inspection therefore focused on following up on previous requirements and any new issues arising. During this inspection two of the residents were met, and the manager/owner was interviewed. Records, care plans and the building were also examined. The recent service user surveys state that the service users feel that the home is bright and clean, good help is provided, there is a choice of fresh nutritious food, the staff are friendly and approachable, and that their wishes are respected and followed. What the service does well: In addition to normal staff supervision records, additional brief supervision sessions also occur and are recorded. The home has a good record of supporting service users in a way that reduces the incidence of relapse and also has a good record for rehabilitating service users and moving them on to independent living. The latter was also supported by comments from the service users. Bedrooms were assessed as exceeding the minimum size standard at this inspection. See also service user survey results in the summary above. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 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 DS0000028584.V282358.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home provides most of the information needed for potential residents to make an informed decision about moving in to the home. EVIDENCE: The last inspection report contained the following requirement: The Statement of Purpose must contain all the elements of Schedule 1, in particular, the relevant qualifications and experience of the managers and staff, the number of staff and the number and size of the rooms in the home. This has now occurred and this requirement is now met. The last inspection report also contained the following requirement: The Service Users Guide must contain the views of the service users. This has now occurred and this requirement is now met. Standard 1 is now assessed as met. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. Residents’ assessed needs, changing needs and how the home meets these needs are not all fully recorded. This could affect the home’s ability to meet and show how it has met all a resident’s known and changing needs. The service users are generally well and safely supported to take risks as a part of independent living. EVIDENCE: The last report recorded that files were sampled and care plans were available for all service users. These were all regularly reviewed and updated but they did not reflect all the elements required under Standard 6.2. In particular social, educational, employment and religious and cultural needs were not included. The following requirement was set under Standard 6 to address this shortfall. 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 social, educational, employment and religious and cultural needs must be included. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 10 Although the care plans have now been updated to include all of the service users’ needs, these now need to record actions required to fully function as a working document. The previous requirement is met and the following new recommendation is now made: Care plans should record actions required to fully function as a working document. To provide potential new service users, relatives and professionals with all the information needed to make an informed decision about the home, the Statement of Purpose now contains the qualifications and experience of the and staff and the number and size of the rooms in the home. The service users guide also now contains the views of the service users. The last inspection report contained the following recommendation: Free access to the sharp kitchen knives should be risk assessed. Free access to the sharp kitchen knives has now been risk assessed. Risk assessments have now been completed for all existing restrictions of liberty required for the protection of service users. This recommendation is therefore currently met. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. Details of previously identified good practice that are referred to elsewhere in this report are however included below. EVIDENCE: Standard 11: The home has a good record of supporting service users in a way that reduces the incidence of relapse and also has a good record for rehabilitating service users and moving them on to independent living. The latter was also supported by comments from the service users. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Residents’ medication is well managed to ensure maximised good health. EVIDENCE: All except one service user manage their own medication. The Registered Provider maintains a list of all current medication, but otherwise the service users retain, administer and control their own medication. All have their own keys to their bedrooms so that they can keep their medication safely. Records for medication administration have been 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. The last inspection report recorded that consent to medication was not recorded on files sampled. The following recommendation was therefore set: Consent to medication and first aid should be recorded. This had occurred by the time of this inspection and the recommendation is therefore now met. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. 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: There have not been any complaints made to the home or the Commission since the last inspection. 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. Most service users emphasised how good the home was although one has previously stated that they were not happy there. There have been no adult protection concerns raised regarding this 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. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25 and 30. The home is hygienic and clean. This environment therefore facilitates the residents’ health and emotional well-being. Additional information regarding bedroom sizes is however included below. EVIDENCE: Information at this inspection was provided to confirm that bedroom sizes exceed the minimum size standard. Standard 25 The last inspection report recorded that the building was observed to be clean and tidy and the home gave the impression of a clean home. It was pleasing to see this was also the case at this unannounced inspection as it demonstrates consistency in this area. In addition recent service user surveys also confirmed this view. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. Laundry facilities have easily cleanable non-permeable floors and easily cleanable walls. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. Details of previously identified good practice that are referred to elsewhere in this report are however included below. EVIDENCE: Staff supervision records were sampled at the last inspection. These showed that supervision was at least of the frequency required under Standard 36. The supervision pro-forma provides for a structured supervision session. Both the supervisor and supervisee sign the record of supervision. The following good practice was identified under this Standard 36: In addition to normal staff supervision records, additional brief supervision sessions also occur and are recorded. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42. Although there is a quality assurance system there is no annual development plan which would provide service users with fuller inclusion in developments in the home and 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: There is a quality assurance system, which involves service users. The quality assurance tools include the complaints system, service user meetings, one to one discussions, user satisfaction surveys, and inspections. There was however no annual development plan to record improvements and to allow the service users concerns to be included in development and improving quality. The following requirement was set at the last inspection to address this: Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 17 The results from user/relatives satisfaction surveys must be collated. An annual development plan must then be produced which reflects the survey results and information from other quality assurance tools. This then needs to be made open to the service users, to allow measurement of achievement in improving quality. This has not been finalised yet, however the timescale agreed has not expired yet. The requirement will remain until fully met. The last inspection report recorded that all of the procedures and testing of systems required in Standard 42 were also present, except the record of regular tank testing and system cleaning to control the risks of Legionella. This had however been applied for. The following requirement was set to address this: The results from the bacterial analysis of the water supply must be sent to the Commission. This has now occurred with no bacteria found. This requirement is now therefore met. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 18 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 3 2 x 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 x 25 4 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 x x 3 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 x x x 2 x x 3 x Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 19 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 39 Regulation 24,1,2,3 Requirement The results from user/relatives satisfaction surveys must be collated. An annual development plan must then be produced which reflects the survey results and information from other quality assurance tools. This then needs to be made open to the service users, to allow measurement of achievement in improving quality. {the existing timescale has not yet elapsed.} Timescale for action 01/04/06 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 6 Good Practice Recommendations Care plans should record actions required to fully function as a working document. Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Manon House DS0000028584.V282358.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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