Inspection on 03/11/06 for Maple House

This inspection was carried out on 3rd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 28/09/05

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 John Vaughan Unannounced Inspection 3rd November 2006 10:10 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 Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000012151.V316726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor House Nursing Home Address 23 Manor Road Aldershot Hampshire GU11 3DG 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) 01252 325753 01252 341963 Dr Zyreida Denning Mrs Lindsey Virginia Long Care Home 30 Category(ies) of Dementia (6), Dementia - over 65 years of age registration, with number (34), Old age, not falling within any other of places category (34) Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 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. 28th September 2005 Date of last inspection 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 two 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. The weekly fee for a place in this home ranges from £550.00 to £700.00. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included two visits to the home the second visit was arranged with the manager. The inspector spoke to service users during the visit. The inspector met with the manager, deputy manager and a number of staff during the visit. Staff were interviewed and observed and records held in the home were sampled. The inspector also toured the home. What the service does well: What has improved since the last inspection? Food is stored and labelled correctly. Fire records are accurately maintained including the checks on safety equipment. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 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 Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home can demonstrate that service users needs will be correctly identified and acknowledged. This home does not provide intermediate care. EVIDENCE: The inspector looked at four service user’s records during visit to the home. Detailed assessments were seen on service user’s files with information on their healthcare, social, mobility and personal care needs documented in the assessment. The inspector was also able to see care plans linked to the assessed needs. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 9 Service users funded by adult services also had evidence of an assessment and involvement of a care manager was seen on this service user’s file. The inspector also had the opportunity to talk to service users who said that the home provided opportunities for their representatives to visit the service and an information pack was also provided to help them to know what would be provided in the home. During the inspection people were visiting to look around the home. The home does not provide intermediate care Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the practice of the home demonstrates that service users needs and wishes are acknowledged and responded to and that the home provides support for service users to access health care professionals to meet their needs and that service users are treated with respect and their dignity is maintained there are serious concerns that the medication administration procedures are unsafe and do not demonstrate that service users are protected. Urgent action must be taken to improved this practice to demonstrate that service users safety is maintained. EVIDENCE: All four service user’s files had clear assessments of need and a care plan. The care plan contains support information covering areas of personal care, health, mobility, communication and likes and dislikes. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 11 A moving and handling assessment is in place, falls assessment and a general risk assessment are on file to support service users to keep safe. Additional guidelines were in place for service users who are confused and this included a method of approach to ensure a consistent approach. The home has also started to introduce a new booklet to develop person centred planning. Service users have been involved in completing these booklets and work is underway to put these plans in place for all service users. The files examined provided evidence of health care professionals in the care of service users. Service users told the inspector that they see their GP when needed and there are places that they can see visitors in private. The medication practices were examined and this included looking at the storage and administration of medication. Records were up to date however when checked against the actual medication a number of errors and omissions were found the inspector found that a number of drugs had been signed for by staff and this medication was still present in the medication containers. This was brought to the attention of the manager who took action to investigate this concern. General medication is stored securely however the inspector was told that the medication fridge had a faulty lock and could not be secured. The fridge is located in a communal area accessed by staff, visitors and service users. This is a potential risk to service users and a temporary move of the fridge to a more secure place was discussed with the home until a safer solution was reached. The inspector was told that the pharmacy provided training to staff and the head of care is responsible for the monitoring of medication practices in the home. Service users said that they felt well cared for by the staff and they feel that they are treated with respect and that they have never had any concerns and staff have always been welcoming and polite. The inspector observed staff talking to a supporting service users and this was carried out with sensitivity and respect. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive a service that meets their social and leisure needs and this is enhanced by a home that welcomes and encourages family contact. The practices in the home support service users to make decisions about their lives. Service users receive a balanced and varied diet reflecting their likes and dislikes, however improvement to the catering facilities and practices would enhance this practice. EVIDENCE: The homes assessment records include information on service users likes and dislikes and their cultural and spiritual needs. The manager told the inspector that regular visits take place by a member of the clergy. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 13 During the visit to the home the inspector observed family members visiting the home. A service user said that there are no restrictions on visiting and their family is always welcome. This person also told the inspector that they pursue their own leisure activities including trips out with their family and visits to the pub for a meal. The inspector observed the day-to-day activities in the home. During the visit a clothing retailer visited the home and service users browsed the rails of clothing and bought some items supported by staff. An activity worker is employed by the home and they have set up a weekly activity programme. Service users have opportunity to take part in activities such as arts, music and movement, a reminiscing group, sherry morning and a quiz session. The manager provided a menu plan and this provided evidence of a wide range of meals and light snacks being offered. A lunchtime meal was seen by the inspector this was well presented and looked appetizing. Service users ate their meals in the dining room and were not rushed. Some service users choose to have their meal in their room and a service user commented that they have plenty of time to eat their meal. Service user’s care plans and assessment information also included specific information on food and snack preferences and care plans are in place to support service users who need additional help with eating and drinking. The inspector looked at the catering facilities in the home, the fridge in the kitchen had a temperature monitoring sheet in place however the temperatures recorded were generally over the safe storage guidelines and no action had been taken. The manager suspected an inaccurate thermometer and commenced a new procedure for monitoring these temperatures. The inspector advised that staff completing these records need to be clear on what actions they should be taking if the temperatures exceed the guidelines. The kitchen is not suitable for the preparation and cooking of main meals for the home and these are delivered from another service belonging to the provider. The manager explained that a planning application has been submitted for a new extension to the building to provide better catering and laundry facilities. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the home has systems in place to acknowledge and respond to their concerns and procedures to protect service users from abuse are in place EVIDENCE: A complaints policy and procedure are in place and available to all service users and visitors to the home. The inspector checked the complaints log confirming that complaints have been made and responded to be the home. The manager was advised to record her actions and the outcomes of any investigation in more detail as it was unclear from the current record what the findings of the investigation of some complaints were. This will help with the review of concerns and complains. The manager put a more detailed form in place for future use. Service users said that they knew how to raise a concern if they needed to and would talk to staff or the manager if they were unhappy. They were confident that the staff team and the manager would listen them to. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 15 Staff have received training in the protection of vulnerable adults and were confident in explaining to the inspector how they would report any concerns they had to protect service users. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with an environment that is clean, comfortable and spacious and each service user has bedrooms that have been arranged to meet their needs. Some work is required to improve toilet facilities and address concerns about unprotected radiators and items obstructing the fire exits to demonstrate that the environment is safe and fully meets service user’s needs. EVIDENCE: The inspector toured the home with the assistance of a member of staff. The home is spacious with a number of rooms that can be used by service users. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 17 The inspector had the opportunity to view a number of service users rooms and these were clean and in a good state of repair. Most rooms had been furnished with personal items and belongings and service user’s said that they were happy with their rooms. Communal areas were bright and had been recently redecorated. The dining room had a new laminate floor. During the tour of the home the inspector noted that a radiator in a service users room had been removed. The staff member reported that work had been recently carried out on the heating system and the plumber had removed this cover. No risk assessment was put in place and the service user is potentially at risk of injury from the hot surface of the radiator. The inspector observed a bench and trolley outside of a designated fire exit, this did not obstruct the door however anyone attempting to leave the home in an emergency would be prevented from moving more than a couple of feet outside and if a large number of people left via this exit they could not safely move away from the home. The manager was required to take action to resolve these concerns and the handyman located and refitted the cover and removed the bench from outside of the door. A toilet close to the main entrance has had the door removed and a curtain is the only separation service users have from a busy corridor and this affects the privacy and dignity of service users. The manager explained that the cubicle door and panel was removed to improve access for the hoists as concerns had been raised about health and safety due to the limited access. They are waiting for further work to be carried out to put in a new doorway. The home was clean and tidy and staff were observed to work hard to clean and keep the home free from any unpleasant smells. The home has a small laundry room this was clean and tidy and kept locked to prevent accidents to service users. Aprons and gloves were seen in use in the home and handwashing facilities are available in the laundry. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home can demonstrate that their current recruitment practice is thorough and ensures only suitable staff are employed in the home. Service users receive support from a staff team that are trained and supervised to meet their needs however it cannot be fully demonstrated that service users are in safe hands at all times due to serious medication failures. EVIDENCE: The staff records provided evidence that mandatory training in areas such as first aid, moving and handling, health and safety and fire safety have been updated and a training record is in place to support this. Staff members have also attended training in protecting service users from abuse. A range of update training is also provided for trained nurses including catheterization, use of syringe drivers and clinical record keeping. Inductions take place in the home and staff are also obtaining National Vocational Qualification (NVQ) awards. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 19 The medication errors previously referred to in this report raise serious concerns about the safe practice of staff and there ability to meet service user needs. The inspector interviewed a three staff and they confirmed that this training has taken place. Staff members that do not have English as a first language attending support groups in the home to improve communication. The manager also encourages staff to speak on topics at staff meetings to improve their conversational English. Staff also told the inspector that they have supervision and support sessions to help them understand and develop their role. The home provides support to service users who can be very confused and at times aggressive. Staff reported that they had undertaken training in supporting people with dementia and managing aggression. The inspector examined the records of all new staff who have been recruited to the home since the last key inspection. All files contained information on the individual. Two written references and proof of identity was also in place. Criminal Record Bureau (CRB) and Protection of Vulnerable Adults register checks have been completed. The manager told the inspector that they had encountered difficulties with the recruitment of some staff from overseas and although this has been resolved now it was initially difficult to obtain information. The manager stated that they are no longer recruiting in this way. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a service that is managed in a generally effective and open manner however some areas need to be addressed to fully demonstrate the effectiveness of this management. The service can demonstrate that a system is in place to develop the service with views from service users and their families included in this process and the home’s equipment is maintained and serviced to keep people safe. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager has qualifications in care and had completed her NVQ in management. Some areas have been identified within this report including safe administration of medicines, the covering of radiators and keeping fire exits clear from obstructions to that are directly related to the management of this service and will need to be addressed to demonstrate that the home is well managed. The manager has developed a quality assurance programme. Evidence was available to demonstrate that service users and their families have been able to share their views on the home. Questionnaires have been completed and the manager organises regular meetings with service users and a relative meeting is also held. The manager has developed an annual business plan addressing areas in need of improvement. The environment and equipment has been focussed on and new equipment has been identified and purchased to improve the care and comfort of service users. Service users leave money for safe keeping with the home and this is usually held in the office. The manager is currently collecting and holding this money in her office as the administrator in on maternity leave. A record is maintained for each person with receipts for transactions. The home provided records to demonstrate that fire checks and tests are carried out regularly. A fire drill and practice was carried out on the day of the inspection. Certificated and records are in place to demonstrate that heating and alarms systems are serviced appropriately and moving and handling equipment is also serviced. Portable appliance check is also completed. The manager is also introducing a detailed environmental risk assessment for each room. Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X X STAFFING Standard No Score 27 2 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP9 OP9 Regulation 13 13 Requirement The registered person must ensure that medication is stored safely at times. The registered person must ensure that all medication is administered and recorded correctly as prescribed. The registered person must ensure that the curtain in front of a toilet is replaced with a door that offers privacy to service users. The registered person must ensure that service users are kept safe from the risk of burns from unprotected radiators. The registered person must ensure that fire exits are kept free from obstructions at all times. Timescale for action 04/12/06 04/12/06 3. OP21 23 04/01/07 4. OP38 13 04/12/06 5. OP38 13 04/12/06 Manor House Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 24 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 Nursing Home DS0000012151.V316726.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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