Inspection on 28/09/05 for Maple House

This inspection was carried out on 28th September 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 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

Maple House 25/07/07

Maple House 03/11/06

Maple House 07/04/05

Maple House 20/10/04

Maple House 28/06/04

Maple House 03/03/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Manor House Nursing Home 23 Manor Road Aldershot Hampshire GU11 3DG Lead Inspector Val Sevier Unannounced 28/09/05 10.30am 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 Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Manor House Nursing Home Address 23 Manor Road, Aldershot, Hants, GU11 3DG 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) 01252 325753 Dr Zyreida Denning CRH 30 Category(ies) of DE, DE(E), OP registration, with number of places Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the DE category can only be admitted between the ages of 55-65 years. Date of last inspection 07/04/05 Brief Description of the Service: Manor House is a nursing home able to accommodate 34 service users. It is situated off of one of the main roads into Aldershot. The service offered is for older people with mental health frailty and nursing needs. The accommodation is offered over two floors with twp lounge areas and a separate dinning room, seating is also available in the conservatory. The home has a garden area accessed from the conservatory, which has seating available. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 4 and half hours. This was the second statutory inspection to the home. A new manager has been appointed to the home since the last inspection and the inspector was able to speak with her regarding her plans for the home and what she has accomplished so far. The proprietor Dr Denning also visited and the inspector was able to speak with two relatives, 4 staff and 2 residents. Many residents were unable to express themselves due to mental frailty but interaction between staff and residents was seen. What the service does well: What has improved since the last inspection? There were several requests for action from the last inspection and it was seen that the home has achieved these. The storage and administration of medication has improved since the last inspection. There has also been an improvement in the recruiting of staff with all relevant checks having been carried out. The care plans were seen and they have identified needs and action for staff to care for the residents. There were daily notes on residents and the care plans had been reviewed. During the observed interaction between staff and residents the staff spoke with the residents and said what they were doing, the staff always spoke in their own language. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 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 Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 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 Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 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, 4 and 5. 6 does not apply at this home The home has an understanding of residents needs using the assessment process. The staff seem to have a good knowledge of residents support needs. There is sufficient information to help relatives and prospective residents in their decision about moving to the home. EVIDENCE: The homes statement of purpose and service users guide are currently being updated, but the inspector was able to see that there is information for prospective residents and families to be able to make an informed decision about the home. The inspector looked at 4 care plans and each individual had had an assessment prior to moving to the home. The assessments have information about physical and psychological needs of the individuals. It was observed that the information gained through the assessment had been used to complete the care plans. A relative spoken with on the day, explained what had happened at the assessment for her relative and how she had been involved when the resident was unable to speak for them. The relative felt that the needs could be met. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 9 The inspector was able to observe interaction between the staff and residents at the home. Staff spoken with said that they had undertaken training in dementia and communication and this was evident in the observed interaction. This is an improvement on the previous visit. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 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 and 11. There has been a gradual improvement in the care plans and the information in them since the manager joined the home, with involvement of other professionals as needed. From the last inspection it was seen there has been a big improvement in the management of medication. Staff were seen to behave appropriately with residents identifying their emotional and physical needs. The arrangements for understanding an individual’s needs in their final weeks give a very clear guidance for staff in caring for those who are dying. EVIDENCE: The inspector looked at 4 care plans to follow up on action needed following the last visit to the home. The care plans had been reviewed regularly and there were daily notes giving the inspector an idea of the daily lives of those residents. The plans indicated the needs of the individuals and the action the staff needed to take to support them this included one person whose behaviour was unpredictable. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 11 Health needs were seen to be addressed; one person needed regular dressings to pressure areas that they came back from hospital with. The same individual is very poorly and the care plans reflected the care needed and how staff were to carry it out, one person is allocated to ensure that needs are met each shift and there was a care plan to address pain. This ensured that the individual even without verbally communicating their wishes would receive pain relief. From written evidence of care plans and speaking with staff it would appear that the staff are equipped with knowledge and skills to care for the needs of people at the home. It would also seem speaking with staff and relatives that no one is afraid to ask questions about issues of concern about needs. There is a noticeable improvement in the medication records seen, and the new manager is undertaking regular audits. The disposal of medication was discussed with the deputy, following policy changes in the manner in which this is undertaken, staff are aware of the changes and their responsibilities. Staff were observed speaking and assisting the residents with dignity and respect. Affection was given appropriately to those residents who sought it. It had been seen on care plans that the preferred choice of name had been recoded and staff were heard to speak to residents by the name they wished. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 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 and 15 The provision of activities at the home goes some way to meet the social needs of the individuals living there. Dietary needs of residents are catered for with a varied selection of food that seems to meet resident’s tastes and choices, this is an improvement. . EVIDENCE: The manager told the inspector that since joining the home she has appointed an activity person to work 20 hours per week a variety of activities are undertaken and staff and relatives said that the residents seemed to enjoy them. The residents said that they liked ‘doing things’ and that the lady was nice. The kitchen was seen which due to its size is only used to prepare breakfast and supper. The lunchtime meal was seen to be tested to ensure that it was hot enough and was served appropriately. Staff were seen to support residents as needed eating their lunch. A relative was assisting her husband and she said that the meals were okay and was having lunch herself there that day. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 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 standard(s) 16, 17 and 18 It would seem the staff in conjunction with the manager are working at establishing a sense of openness at the home so that relatives and residents can voice their concerns. Staff feel that they can voice concerns especially regarding the care of the residents. EVIDENCE: There has been one complaint made at the home since the last inspection, and one to the CSCI. The manager explained the action taken regarding the complaint at the home. The inspector spoke with staff about the complaint received at the commission which at the time of the report is not resolved. Relatives were aware of how to complain and said they felt comfortable in speaking with the manager or deputy about any issues. There have been no allegations regarding adult protection at the home. The manager undertakes training the staff in this area, and staff spoken with were aware of the whistle blowing policy and the training. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 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 standard(s) 20, 21, 22, 23, 24, 25 and 26. The standard of the environment is satisfactory providing residents with an attractive and homely place to live. EVIDENCE: The inspector walked around the home accompanied by the deputy several rooms were sampled and seen to be ‘homely’. There are nursing beds available as needed; with specialist mattresses for pressure are care. A new electric hoist has been bought since the last visit to the home and the staff feel this has improved their ability to move people safely. The manager has undertaken an audit of the environment and has identified areas that need some work and she has discussed them with the owner, this includes the showers and baths. The laundry was locked for safety and there was evidence that the staff keep the room clean and attend to the tumble dryers. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 15 There was a strong odour in several areas when first entering the home and during the walk around. Before the inspector left she checked again and the housekeeping staff had worked hard and had eliminated the cause and odour. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 16 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) 28, 29 and 30 The level of staff and training programme would seem to meet the needs of the residents. The recruitment process and checks to ensure residents safety have improved since the last inspection. EVIDENCE: The manager explained that she has been looking at the staff and the skill mix and abilities. She has begun to recruit staff to give a cross section of abilities and this seems to be working well. There are several adaptation nurses working at the home who support the nurses and the care staff have or are undertaking NVQ qualifications. A cook has been employed two or three days a week to cook the supper and bake cakes fresh at the home. A maintenance person has been employed also. The home has a clear and improved recruitment policy that covers all the elements for the protection of residents including criminal records checks and references. The two staff files that were read evidenced that this policy was being met. The manager has undertaken appraisals of the staff and has identified areas for training; some of these have been arranged and include infection control and foot care. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 17 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, 36 and 38. The manager has a clear vision for the home, which she has effectively communicated with staff. There is clear leadership and staff support and training so that the needs of residents can be met. There are areas of the home where a lack of attention to health and safety places the residents at risk. EVIDENCE: The manager has been at the Manor House for only a couple of months having previously worked in other nursing homes as a trainer and at on stage owned her own nursing home. She is a nurse, assessor and manual handling instructor. She is currently undertaking the NVQ 4 in management and she has applied to the CSCI for registration. Since starting at Manor House the manager has had several meetings with staff explaining her expectations and plans for the home. A meeting with Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 18 relatives is planned for October. The manager explained that a letter had been sent out regarding personal accounts and that the home was to pass the care of this back to the relatives or responsible person. The manager has carried out appraisals on all staff and has nearly finished supervisions. She has planned supervisions over the coming year and this will full fill the six expected under the standards. The manager has undertaken a health and safety audit including a visual assessment of the equipment this has produced an action plan which includes new equipment and discussion with the owner. Fire training has been carried out twice this year in April and September. The fire brigade visited in July and requested several areas of action these have been carried out. There were records of weekly fire alarm tests and visual checks monthly of the emergency lighting. There were no records regarding the visual checking of fire extinguishers, although the fire safety company used by the home changed some in June. The kitchen staff undertake checks of fridge temperatures and the kitchen was reasonably clean. However in the fridge there were three lots of foods covered with no dates or labels indicating when they should be used by. Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 19 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 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 x 3 3 3 x 3 x 3 x 2 Manor House Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 20 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. 2. Standard 38 38 Regulation 16 2(g)(j) 23(4) Requirement All food stuffs must be dated and labelled when stored in the fridge. Sufficient checks and records must be kept regarding fire safty equipment. Timescale for action 29/09/05 30/09/05 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 Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 21 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton, Hants SO15 1GW 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 Nursing Home H54 s12151 Manor House V244705 280905.doc Version 1.40 Page 22 - 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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