Inspection on 16/05/05 for Manor House

This inspection was carried out on 16th May 2005.

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

Other inspections for this house

Manor House 27/04/07

Manor House 03/11/05

Manor House 10/08/04

Manor House 11/05/04

Manor House 21/02/04

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 Manor House London Road Morden Surrey SM4 5QT Lead Inspector Jean Stuart Announced 16 May 2005 9:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Manor House Address London Road Morden Surrey SM4 5QT 020 8648 3571 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Dudley Sessford Mrs Hellene Sessford Care home only (PC) 23 Category(ies) of Old age, not falling within any other category registration, with number (OP)- 13 beds. of places Demetia over 65 years of age (DE(E))- 10 beds. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10.8.04 Brief Description of the Service: Manor House is a registered care home for up to twenty three elderly people, ten of whom may have dementia. The home is on two floors of a detached property and is situated within a residential area of Morden. Parking is to the side of the home. Public transport bus services are within a short distance of the home. All bedrooms have ensuite facilities. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day in May 05. A brief tour of the premises took place and care documentation was inspected. Ten residents and three members of staff were spoken to individually, and in the afternoon a discussion was held with a group of residents. What the service does well: What has improved since the last inspection? What they could do better: The manager reported that she would like to use her developing management skills (NVQ four training) to improve the quality of the paperwork at the home. The manager agreed with the requirements set by the inspector. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 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. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,6. Prospective residents have the information they need to make an informed choice about where to live. EVIDENCE: The home has a Statement of Purpose and a Service Users guide, which provide information on the home, it’s aims and objectives and the support available. One resident reported that the family had the opportunity to visit this home and other homes before a decision was made to move in. The resident reported that the home suited, it meets their needs because it respected a wish to spend the day in the bedroom and not to socialise. If the local authority makes an application for a resident to move into the home, the staff from the social services department carries out an assessment of the needs of the person. A copy of the assessment is supplied to the home and placed on the individuals file. In addition to this the manager will complete her own assessment on the prospective residents. This includes the individuals’ needs and preferences. This information is then used to draw up a care plan for the individual. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 9 The home will only occasionally offer intermediate care. Currently all residents in the home are long stay residents. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10. Care plans are in place for individual residents. The health care needs of individual residents are met. EVIDENCE: Good information was seen on the personal and health care needs of residents Care plans were sampled. The care plans reflect the needs of residents. The documents also provide information on the social needs and wishes of individual residents. Risk assessments are available for staff to monitor any issue that might place the residents at risk, and how this is to be managed. The needs of one resident have changed recently. The changes were noted on the daily recording. The manager described how the home now provides care for this resident, who presents behaviour that is challenging. How they provide care is not reflected in the risk assessment. The level of detail documented in the risk assessment was limited. The details are an important indicator to staff of how this resident’s needs can be met and they must be added to the risk assessment. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 11 The daily recording made by care staff is maintained on the computer. This was up to date, comprehensive and informative. Individual staff that place their name next to the entry completes this record. A handover book is also filled out to ensure that staff coming on duty have an immediate record of what is happening to residents and how their needs may have changed. All residents are registered with local GP practices. Advice is sought from specialist nurses if needed. On the day of this visit a specialist nurse was visiting the home and reported that any instructions left with the home are “followed through” to ensure the resident’s needs are met. Arrangements are in place for a hairdresser, chiropodist, optician and dentist to visit the home on a regular basis. One resident reported that they had seen the optician. All of the residents had tidy hairstyles. A record of medication coming into the home and of administration was well maintained. At the time of the visit no one was self-administrating. A medication profile , listing the medication each resident is taking, was in place. Staff have received accredited training in medication. Residents reported that “people are so kind”, and they “feel safe”. Manor House is a “friendly place and I am happy here”. Staff are “very nice” and “treat you with respect”. Staff were observed to offer assistance and advice in a discreet manner. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15. Residents reported that their preferred life style is accommodated within the home, and they can exercise choice about how they wish to live. EVIDENCE: Residents confirmed that they are free to join in activities according to their own wishes. A resident reported that there “are things to do” at Manor Lodge. There is an activity person who visits Monday to Friday, and they do quizzes, have chair exercises, play bingo and sometimes go out. A resident spoke of a summer barbeque, family and friends will be invited to this. The activities organiser was on annual leave and alternative arrangements had been made to cover her duties. Arranged activities were seen through out the day. In the morning a person who played the keyboard visited and played tunes that were known to residents. The majority of residents moved their feet and hands to the music, some sung. When asked by a member of staff if they would like to see this person again, all agreed they would enjoy that. At lunch time a resident had commented that painting was one of the activities and they plan to develop painting skills. After lunch a few residents sat in the dining room, and played Ludo with obvious enjoyment for this competitive game another resident painted. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 13 Discussions with residents indicated that meal times are flexible with regard to breakfast and supper. They stated that they have breakfast in their own room, lunch is served in the dining room, and one resident reported that supper is always served in her bedroom. All residents agreed that the “food is good”, one residents said “I love the food”. A good variety of food is on offer with an alternative being available every day. Special diet are catered for. A record is maintained of the food served, demonstrating that residents receive a wholesome and appealing balanced diet. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18. The home has a clear complaints procedure. Residents stated that if they had a complaint they could take it to the manager and it would be dealt with. EVIDENCE: A record of complaint is kept in the home. This record includes information on any investigations and out comes. Information on what action needs to be taken should there be an allegation or suspicion of abuse is in place. Three members of staff were spoken with, and reported that they had attended the local authority training on abuse. Postal voting was used in the general election to ensure that residents could take part in the election. Fourteen survey forms were returned. All stated they feel well cared for. On the survey form is a question, if residents “are unhappy with their care do you know who to speak to”. Six resident returns reported a “no” response to this. The manager reported that she is to ensure photographs are taken of all keyworkers, and these will be placed on the notice board, with a reminder that keyworkers are there to speak with and help. During this visit resident and staff interaction was most positive. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26. Residents live in a comfortable well maintained environment, with a homely atmosphere. EVIDENCE: The home is well maintained with furniture that the residents find comfortable. An occupational therapist has carried out an assessment of the home, and the home is adequate to meet the needs of elderly people. Many of the residents were observed using sticks or walking frames to get around the building. The home has a lift for residents who can not manage stairs. All bedrooms have ensuite facilities and one person spoke of how nice it is to have their own bathroom. Bedrooms all had personal processions, which helped to make the room “home” for residents. The manager reported that an estimate has been taken for selected radiators to be guarded, and this work will take place in the summer There is a good level of cleanliness through out the home. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 16 The home has a large well maintained garden. Residents stated they enjoyed sitting in the garden Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. Staffing levels are adequate to meet the current needs of residents accommodated in the home. A committed staff team supports residents. EVIDENCE: In the morning the manager, a shift leader and three carers were on duty, plus a cleaner, a cook and a maintenance man. There is a low turnover of staff, which provides residents with stability and consistency. The staff team have the necessary skills to meet residents’ needs. The manager is a qualified nurse and is completing the NVQ four training. A member of staff is completing NVQ level two and reported that they will move straight on to level three training. Other staff are completing NVQ level two training. Staff records show that courses have been completed in abuse, dementia, moving and handling, and first aid. As seen on the day of this visit that staff discuss residents needs at the start and finish of the shift. Staff receives one to one formal supervision, this helps them to share experiences of the care given and to develop their knowledge of the services given. Annual appraisals are in use. Comments from residents include “staff are very nice, very kind they treat us with respect”. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,35,36,37,38. The manager communicates a clear sense of direction and leader ship in the home. The home is run in the best interests of the service users. EVIDENCE: Residents reported that they have an opportunity to meet with the manager when ever she is in the home. The manager has made efforts to engage residents and their families and friends by providing social occasions for all to attend. One resident reported about the manager that “nothing is too much trouble for her”. Residents meetings are held and this provides an opportunity to influence the running of the home. The most recent meeting involved suggestions about the menu, the laundry, and a wish to listen to classical music in the lounge. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 19 The manger produced a business plan for the home, figures must be produced to support this. Money is held for some of the residents, the policies and procedures of the home help to protect residents from financial abuse. A good record of financial transactions are maintained. Staff ensure the health and safety residents by carrying out regular checks around the home for example medication and water temperatures are checked regularly. Staff receive regular supervision of working practices. Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 x 3 3 3 3 3 Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 21 yes 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 7 Regulation 15 Requirement The registered person must ensure that detailed risk assessments are completed for all residents. The registered person must ensure that pipe work and radiators are guarded or have low temperature surfaces. (Repeat previous timescale of 31/8/04 was not achieved). The registered person must ensure that there the business plan is supported by the cost of this plan. (Repeat previous timescale of 31/8/04 was not achieved). . Timescale for action 1 June 05 2. 25 13(4)(a) 30 July 05 3. 34 25 30 July 05 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 Good Practice Recommendations Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Manor House G54-G04 S27225 Manor House V220412 160505 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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