Inspection on 03/11/05 for Manor House

This inspection was carried out on 3rd November 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 16/05/05

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 Unannounced Inspection 3rd November 2005 02:00 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 Manor House DS0000027225.V263846.R01.S.doc Version 5.0 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. Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manor House Address London Road Morden Surrey SM4 5QT 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) 0208 648 3571 Mr Dudley Sessford Mrs Helene Sessford Mrs Helene Sessford Care Home 23 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (23) of places Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16 May 05. 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 DS0000027225.V263846.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the afternoon of 3 November 05. A brief tour of the premises took place and care documentation for three service users was inspected. Ten service users were spoken to individually and eight members of staff were observed in staff handover between shifts. The inspection took three and a half hours. What the service does well: What has improved since the last inspection? Radiators have been repositioned to safeguard residents from harm. The arrangements for handover have been developed. Not only is a record kept on the computer but a handwritten log is maintained, giving staff easy access to information. Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 6 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. Manor House DS0000027225.V263846.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Manor House DS0000027225.V263846.R01.S.doc Version 5.0 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 the following standard(s): 1,3,4,5. Service users and their families have the information they need to make a full assessment of the home. A welcome pack describing the facilities and services is made available. Residents’ benefit from having their needs appropriately assessed before admission. EVIDENCE: A service user who had been in hospital reported their family had visited the home before they moved in. Details of the aim and facilities of the home in the welcome pack, the service users guide and the Statement of Purpose are made available to prospective residents and their family. This ensures that the service user has other people’s views to help make the decision. There is an appropriate procedure to make sure that individual needs of residents are assessed before they move into the home. This includes needs and preferences. Where applicable a Local Authority assessment of the Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 9 resident will be completed by social services and placed on file. The assessments ensure that the individual’s needs are met. Manor House DS0000027225.V263846.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10. The home ensures that care documents are kept. Regular daily recording takes place. Care plans are updated following a change in need or a review. Risk assessments are maintained. The healthcare needs of residents are satisfactorily met. EVIDENCE: Residents reported they are “well looked after”. Three residents reported that staff are always around and are “polite”. After lunch residents were using their bedrooms, a member of staff was periodically checking to see that their needs had been attended to before leaving them alone for the afternoon. Respecting a resident’s right to privacy. Service users needs are reflected in their care plans. Care plans were sampled and reflect the needs of residents. Good information was seen on personal and health care needs of residents. Risk assessments have been completed. By recording the information, service users wishes will not be overlooked by staff. Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 11 The home follows good practice in the recording of medication. None of the current residents self administer their own medication. Staff, in their use of medication, promote a positive and safe environment for all in the home. Manor House DS0000027225.V263846.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14. 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 reported that activities are provided. They “draw, paint, play ludo, dominos, snakes and ladders, and sometimes bingo on a Sunday”. There is an activity person who visits five times a week, and provides two and a half hours each day. Feedback from a resident stated “I am happy here it is good to be busy”. A family member visiting a resident reported that they visited three times a week and I am “happy with the care”. On the afternoon of the inspection one resident had attended a Fellowship group at a local church, the group considers what is happening in Morden. Residents clearly exercise choice and control over their own lives. Discussions with residents indicated that food is “good”. Residents are offered a variety of nutritional food, with an alternative always being available. For supper a member of staff was observed talking to residents about their choice for the meal. Special diets are catered for. A new resident reported that the provider had asked about which meals were enjoyed. A list of meals had been drawn up for kitchen staff. Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 13 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. A satisfactory complaints procedure is in place and is supplied to residents on admission to the home. EVIDENCE: Residents spoken with, expressed confidence in the home to deal with any concern or complaint they might have. One resident was very clear that the keyworker would be told about any concerns. None of the residents spoken to had any concerns at the time of the inspection visit. The home keeps a record of any complaint and actions taken. The last complaint was received on 3.9.04. Information on what action needs to be taken should there be an allegation or suspicion of abuse is in place Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 14 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): 19,20,21,22,23. The home provides comfortable and homely accommodation to residents. The premises are maintained to a good standard of maintenance and cleanliness. EVIDENCE: The communal areas of the home are homely in appearance, and the lounge and dining room provides a pleasant area for residents to use. Many of the residents were observed using walking frames to get around the building, ensuring they are safe when walking. All rooms were very clean and free from offensive odour. Bedrooms are personalised to residents’ own tastes and interests. Individual bedrooms provide comfortable accommodation and each room has an ensuite bathroom. Two radiators have been moved to ensure that residents are protected from falling against a hot radiator. Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 15 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. The home has sufficient staff on duty to meet the needs of the residents. The welfare of residents is protected at all times. EVIDENCE: Residents reported that staff were “very helpful”, and “do everything”. At the time of the inspection the home had twenty-three residents, three care assistants on duty, and a cook. Staff were observed talking with residents and assisting them with personal hygiene. Staff asked residents in their bedroom if they required anything. One confused resident, who was wandering, was encouraged to sit with a cup of tea. Staffing levels and skill mix are adequate to meet assessed and recorded needs of residents. Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 16 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): 32,34. The home is run in the best interests of service users. EVIDENCE: A resident reported that they had met the manager to see how they could make their stay better. The interest of service users are promoted through the home individual’s being encouraged to make their own decisions. When this is not possible relatives are asked their opinion. Residents are given choices as to how they spend their time, activities are provided or help is available when they go out and to make sure a resident is safe an escort is provided. Every effort is made to ensure that residents maintain good health through diet and a special diet will be produced when necessary. The doctor, and the community nurse visits the home when required. Residents go out to the opticians. Risk assessments are completed for any activity that make residents vulnerable. All of these Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 17 activities are recorded and working practice is set out in the home’s policies and procedures. The manager ensures that the home creates an open, positive atmosphere. The manager reported that the figures for the business plan will be produced for the new financial year that commences in November 05. Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 x x x STAFFING Standard No Score 27 3 28 3 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 2 X X X X Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 19 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 OP34 Regulation 25 Requirement The registered person must ensure that there the business plan is supported by the cost of this plan. (Repeat previous timescale of 30.7.05 was not achieved). Timescale for action 30/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Manor House DS0000027225.V263846.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection SW London Area Office 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. 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