Inspection on 29/07/05 for Manor Lodge

This inspection was carried out on 29th July 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

Manor Lodge 09/12/08

Manor Lodge 16/02/07

Manor Lodge 17/01/06

Manor Lodge 06/01/05

Manor Lodge 03/08/04

Manor Lodge 05/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Manor Lodge 27-29 Alexandra Road Watford Hertfordshire WD17 3QX Lead Inspector Yoke-Lan Jackson Unannounced 29 July 2005 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 Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Manor Lodge Address 27-29 Alexandra Road, Watford, Hertfordshire, WD17 3QX 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) 01923 221 451 01923 253 114 Follet Care Limited Mrs Julie Parker CRH Care Home 34 Category(ies) of OP-34 registration, with number of places Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Thre are no additional conditions of registration. Date of last inspection 3 August 2004 Brief Description of the Service: Manor Lodge is a large detached house that has been converted into a residential home for service users in the old age category. By agreement with the Commission, CSCI, (formerly NCSC), the home provides accommodation for 28 service users instead of the registered 34 since four of the bedrooms are smaller than required by the National Minimum Standards. The home is situated in a residential area within walking distance of the town centre of Watford and Watford Junction railway and bus stations. There are a limited number of free parking spaces outside the home.The administrative office, the staff room, the kitchen, the lounge/diner and the laundry room are all on the first floor. Most of the bedrooms are on the first floor. There is a lift to the first floor. The assisted bathroom and toilet facilities are easily accessible. The only communal space is the lounge/diner which is spacious and overlooks the large patio and garden. There are tables and chairs in the garden, where most of the service users spend their lunch time in the summer months. Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection (unannounced) for the year 2005. The deputy manager was present. The inspection centred on environmental issues, medication, activities and general observation of staff performance and their interaction with service users. The standard of care continues to be maintained in a positive way. However, the inspection has identified areas of concern regarding the lack of consistency in maintaining the external grounds to ensure that they are safe and accessible to service users at all times. (Please see below for details of the inspection findings). What the service does well: What has improved since the last inspection? The home has installed a drug cupboard for controlled drugs in compliance with the legislation on storage of medicines. Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.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 Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.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 Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.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, 2, 3, 4, 5. A full assessment is carried out to ensure that the home is able to meet the needs and aspirations of the prospective service user. A trial period of stay is provided. EVIDENCE: The care plans inspected confirmed that a full assessment is carried out prior to admission of a service user. Each service user is given a copy of the contract of terms and conditions with the home. Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 9 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, 11. The service users appeared well cared for. They were treated with respect and dignity. All the service users were given personal support and assistance by the staff. The home complies with legislation in regard to the storage and administration of medication. EVIDENCE: The majority of the service users were in the lounge. The members of staff were on hand to assist the individual service users as the need arose. One service user said: “The staff are wonderful.” Not all the service users were able to respond verbally but they appeared content and clean and were dressed in their own clothes. The care plans examined have detailed accounts of the personal, social and health care needs. The individual care needs are reviewed regularly and documented. The service users are not able to administer their own medication. Only trained staff administer the medication to them. Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 10 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. The service users are given choices in the daily living routine. Their preferences are respected. Meals are a highlight of the day and the service users enjoy the meals provided. Service users are encouraged to maintain links with their family and friends. EVIDENCE: The service users spent most of their time in the lounge/dining room. Each of them tends to sit in their favourite seat and their preference is respected. The service users have three hot meals a day. Mealtime was unhurried. Lunch was served to service users who were ready to have them. Members of staff were observed to respect those service users who wished to have their lunch a little later. There are weekly activities. Some visitors participate in playing bingo with the service users and encourage singing during their visits. Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 11 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. Service users are protected from abuse and their legal rights are protected. There is a complaint process for all service users to access both formally and informally. EVIDENCE: A residents’ meeting is held regularly to allow service users to express their views and to discuss issues before they escalate. Staff are trained to protect service users from abuse and all staff are aware of the Whistle Blowing Policy and Procedures. The home follows the Hertfordshire Vulnerable Adult Policy and Procedures. Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 12 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. The home does not currently provide a safe and comfortable environment for the service users. The external grounds have not been consistently maintained and kept tidy. The lounge/dining room and the hallway are in need of redecoration. EVIDENCE: On the day of the inspection, the patio and back garden appeared untidy with a ladder, loose bricks and various broken objects that were hazards to safety. Since the inspection these have been cleared. The bedrooms appeared neat and clean and free from odour. There were personal items on display that reflect the individual choice and preferences of the service users. Doors have been installed with automatic hold/open door devices. However, the lounge and hallway are in need of redecoration. (Please see Statutory Requirements). Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 13 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, 30. The home has an effective team of workers. The skill mix of the staff benefits the service users. The staff have good knowledge of the needs and preferences of the service users in their care. EVIDENCE: On the day of the inspection, it was noted that the staff were readily available to assist the individual service users in the lounge. The members of staff interviewed confirmed that they have attended various training courses to update their skills in caring for the service users. The staff are currently attending courses on Health and Safety. Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 14 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) 32, 36, 37, 38. The general standard of care and services are maintained in a positive way except that the external grounds have not been kept safe and accessible at all times. EVIDENCE: The registered manager was not present on the day of the inspection. The deputy manager, who was present, has agreed to clear the external grounds of hazards and this has been done since the report was written. The registered manager must ensure that the premises are maintained and kept tidy in a consistent way. Members of staff interviewed confirmed that they have regular supervision. All records are maintained and kept up to date and used in accordance with the Data Protection Act 1998 and other legislation. (Please see Standard 19 and Statutory requirements). Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 15 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 3 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 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 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 x 3 x x x 3 3 2 Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 16 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19.3, 20.0 & 38.3 Regulation 23 (2) (o) Requirement The external grounds must be maintained in a consistent way and be safe and accessible at all times. (The hazards were cleared within the required time scale). The lounge and hallway must be redecorated and maintained in an attractive way. Timescale for action By 5 July 2005 2. 19.2 23 (2) (b)&(d) By 30 September 2005. 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 None. Good Practice Recommendations Manor Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City, Herts AL7 3BQ 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 Lodge I52 s19454 Manor Lodge v242242 290705 stage 4.doc Version 1.40 Page 18 - 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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