Inspection on 04/04/05 for Manor Lodge

This inspection was carried out on 4th April 2005.

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 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 Lodge 22/08/07

Manor Lodge 25/04/06

Manor Lodge 06/09/05

Manor Lodge 17/08/04

Manor Lodge 14/04/04

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 Lodge 32-34 Manor Road Harrow Middlesex HA1 2PD Lead Inspector Judith Brindle Unannounced 4th April 2005 9.45 am 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Manor Lodge Address 32-34 Manor Road Harrow Middlesex HA1 2PD 020 8427 3211 020 8868 8375 www.rmd@ukgateway.net R.M.D. Enterprises Limited 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) Laura Silvia Fernandes CRH, PC 16 Category(ies) of OP registration, with number of places Manor Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17/8/04 Brief Description of the Service: Manor Lodge is a care home providing personal care and accommodation for 16 older people. The care home is owned by R.M.D Enterprises. It is located in Harrow. A short drive from local shops and amenities and from the numerous facilities of central Harrow. Thes amenities include restaurants, cafes, banks, a post office and numerous shops. The home was opened in 1990. It is a detached building, in a residential area. There is parking for four to five vehicles at the front of the home. There are public transport bus and train facilities in Kenton and Harrow.The home has 14 single bedrooms, 4 of which have en-suite facilities. There is also one shared bedroom. There is a passenger lift. The home has an enclosed well-maintained garden, at the rear of the property, which is easily accessible. Manor Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 6 hours. The home had no vacancies at the time of the inspection. The care home has a welcoming, hospitable atmosphere. The inspector was pleased to meet and speak with ten of the 16 service users; two care staff, and one visitor (another visitor kindly spoke with the inspector following the unannounced inspection). The registered manager was on duty the inspection. The inspection included a tour of the premises, with an inspection of a sample of bedrooms, and also bathroom facilities. Care records and other records in regard to the service provided were also inspected. Most of the requirements from the previous inspection had been met. The remaining three requirements were discussed with the registered manager, and need to be actioned by the registered person. What the service does well: The care home has a ‘caring’ atmosphere. Service users spoke in a positive manner in regards to the care home. Service users, and records informed the inspector that staff had understanding and knowledge of how to meet service users needs. There is direction from the registered manager, and service users had awareness of the lines of accountability and were positive in respect of their views of the staff and the manager. Service users and a visitor confirmed that staff were very approachable. Care plans are accessible and clearly recorded and are regularly reviewed. Meals are varied, nicely presented and choice is offered. Residents spoke positively of the meals provided. They confirmed that they have sufficient wholesome and varied food. Resident’s bedrooms are personalised and there is evidence that residents can bring with them personal items. The care home is well maintained. The environment is clean and warm, with furnishings and fittings judged to be of quality. There is a well maintained garden, which service users’ spoke of accessing, particularly during the summer months. Manor Lodge Version 1.10 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manor Lodge Version 1.10 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 Version 1.10 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 and 3 Standard 6 was not assessed due to this standard not being applicable to Manor Lodge. There is information and documentation in regard to the service provided, but this needs to be more accessible. Prospective service users, receive assessment of their needs prior to their admission to the care home. Visits to the care home by prospective service users, and their relatives/significant others are encouraged. EVIDENCE: Service users need to be supplied with a copy of the service user guide, and if they do not wish to have their own copy this needs to be documented. This was a previous requirement. The manager informed the inspector that a copy of the service user guide would be displayed in the home. The inspection report is accessible in the care home’s office, and the manager informed the inspector that relatives/significant others receive a copy of the document, but service users do not receive their own copy. The home has an admission procedure. The registered manager assesses prospective residents needs. The manager informed the inspector, that service users, who are referred by purchasing authorities, also receive assessment of Manor Lodge Version 1.10 Page 9 their needs from a representative of the relevant local authority. The initial recorded assessment format, and an individual assessment summary for each resident was available for inspection. This included assessment of personal care needs, dietary needs, and mobility needs. A copy of the initial assessment should be accessible in the residents’ individual care plan. Residents spoke of having visited the home with relatives/significant others prior to moving in; others gave reasons as to why they had not visited the home. Manor Lodge Version 1.10 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, and 10 Residents’ health care needs are identified and staff action is taken to meet these assessed needs. There has been some progress in the development of recorded staff action guidelines in regard to meeting specific health needs of service users, but there needs to be further development in recorded guidance in regard to staff action to meet these assessed health needs. Medication is stored and administered appropriately. Arrangements for residents’ health and personal care ensures that service users’ privacy and choice is respected. EVIDENCE: Individual care plans are available. Each resident has a care plan, which is regularly reviewed. Service users (if able) need to be more involved in this process. Four care plans were inspected. This sample included one care plan of a newly admitted resident. The care plans inspected recorded individual identified, and monitored, health, personal, and social care needs. This documentation included some staff guidance to meet these needs. A referral of a service user for physiotherapy was recorded. Service users spoke of having of GP appointments, and receiving chiropody treatment, hearing checks Manor Lodge Version 1.10 Page 11 and eye appointments. It needs to be recorded in service users’ care plans if they do not wish to wear a prescribed hearing aid. Residents weight is monitored. Records, and a service user (who expressed concern in regard to this) confirmed that a service users’ weight had increased significantly within four and a half months. The registered manager informed the inspector of the action being taken to assist and support the service user in the management of this weight increase. This action needs to be recorded. Some relatives/significant others are involved in the process of reviewing the care plan. There was no evidence from the care plans inspected of residents being consulted in this process of review. Where it is practicable to carry out such consultation with a resident this needs to take place, and recorded if it is not practicable or when a service user does not wish to participate in a review of their care plan. Records confirmed that service users received risk assessment in regard to falls. There should be a regular review of falls by service users within the care home. The registered manager informed the inspector that there are no residents who have a pressure sore. Information in regard to the prevention of pressure sores was accessible. Medication is stored securely. Information and documentation including the medication policy was accessible. Administration of medication was carried out in an appropriate safe manner during the inspection. There were no gaps in recording in the medication administration records. Staff informed the inspector that they had received medication induction training. Requirements from the CSCI pharmacist inspection in 2004 had been met. Staff were observed to respect service users’ privacy needs, and to interact with service users in a positive and sensitive manner. Residents who kindly spoke with the inspector confirmed this. Residents were observed using a telephone. Others spoke of having access to a telephone. Manor Lodge Version 1.10 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13, 14,and 15 There has been development in the provision of social activities within the home. Progress is being made to provide more variation and interest for people living in the care home. Contact with family/friends is encouraged, and maintained. Appropriate records are maintained of residents’ personal monies managed within the care home. Meals are varied and wholesome. Service users have choice in regard to meals. EVIDENCE: Service users, and staff informed the inspector that service users had recently completed questionnaires in regard to preferred leisure activities, and in regard to the provision of meals. A care staff member has recently included activity worker as part of her role. A programme of activities has recently been developed, following assessment of the questionnaires received from residents. The registered person should ensure that staff (including the activity worker) have sufficient time to introduce a variety of daily activities. Service users who kindly spoke to the inspector confirmed that there was a need for further development in the provision of varied activities within the care home. One service user reported that she would enjoy more exercise sessions. Another resident confirmed that she had participated in a community shopping activity. Staff and residents informed the inspector that residents were offered choice in Manor Lodge Version 1.10 Page 13 regard to whether they wished to participate in activities and that this choice was respected. Individual records were maintained in respect of the activities that individual service users participated in. Service users and visitors reported that residents are able to have visitors at any reasonable time. There is involvement in the home by local community groups. A sample of service users’ monies inspected, were recorded and balanced appropriately. Service users spoke positively about the meals provided, and confirmed that they had completed questionnaires in regard to preferred meals. Staff informed the inspector that changes to the menu were in the process of being developed in response to the questionnaires. The service users reported that they enjoyed the meal provided during the unannounced inspection. Several drinks were provided to residents during the inspection. The meal provided during the inspection did not correspond to the menu displayed. The inspector was informed by the registered manager the reason for this. Changes to the recorded menu should to be clearly identified, and the reason for the change recorded. To avoid confusion any for service users. Manor Lodge Version 1.10 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Procedures are in place for handling complaints objectively. Residents are confident that their concerns are listened too, and taken seriously. Arrangements are in place to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has accessible policies and procedures in regard to complaints, whistle blowing, and for the protection of vulnerable adults. The complaints procedure was displayed in the sitting room of the care home. Service users and a visitor who kindly spoke with the inspector were aware of how to complain and that they would be confident that a complaint would be investigated appropriately. There were no complaints recorded, and the CSCI had not received any complaints over the past year, in respect of the care home. The registered manager reported that she had received protection of vulnerable adults training last year. Records confirmed that some staff had received some in house training in regard to abuse awareness. Some staff had recently completed training in regard to challenging behaviour and dementia care. Procedures were accessible in respect of staff responding appropriately to any allegations of abuse. Manor Lodge Version 1.10 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,24, and 26 The care home is well maintained, clean, warm and homely. Residents’ rooms are personalised. EVIDENCE: A tour of the care home took place. The home and the garden is generally well maintained. A door to a washing machine needs repair. A sample of service users’ rooms was inspected. Bedrooms contained evidence of personal possessions, including evidence of service users’ personal furniture brought, from their previous home. A service user kindly showed the inspector her room. Service users spoke of being satisfied with their bedrooms. A service users’ bedroom had recently been redecorated. The home is warm, clean and free from offensive odours. A domestic staff member is employed. Manor Lodge Version 1.10 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) 27, and 30. Staff were judged as having knowledge and understanding of service users’ needs, but there needs to be sufficient staffing to ensure that the leisure/activity needs of service users can always be carried out, to meet the needs of all service users. It is not clear that there are always sufficient staff on duty at peak times. The manager still is supranumery for generally only one shift a week. . Staff training has been further developed since the last inspection. There should be continued development in regard to staff training. EVIDENCE: Service users’, staff, and records informed the inspector that staff numbers and skill mix were generally meeting service users’ needs. Records and feedback from service users and a visitor informed the inspector that there needs to be review of staffing needs at peak times, such as evenings/bedtimes. This review needs to be recorded. Service users reported that staff were kind and approachable. Staff who spoke with the inspector had an understanding and knowledge of residents needs. During the inspection call bells were answered very promptly. There were two care staff on duty, and the manager (or senior care worker), and a domestic staff member and a cook during the morning of the unannounced inspection. Two staff were to be on duty in the evening. Residents reported that some activities took place, but not always regularly (see Standard 12 recommendation). Manor Lodge Version 1.10 Page 17 A sample of records confirmed that staff received an induction programme, and that some recent appropriate staff training had taken place. There was evidence of some staff having had ‘one to one’ in house training. The content of this training needs to be recorded. Food and hygiene training and manual handling training was planned in June 2005 for staff. The manager being supra numeral for more hours during the week, needs further review, so that she can carry out the managerial role, which includes staff supervision, and the in house training role that she has taken on. The manager informed the inspector that two staff were completing an NVQ in care course. Manor Lodge Version 1.10 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35,36,and 38. Arrangements are generally in place to meet the health, safety and welfare needs of residents. There has been development in regards to monitoring the quality of the service provided. Safeguards are in place to protect the residents in respect of support given to service users in the management of personal financial transactions. There has not been required progress in providing all staff with regular formal supervision. This was previously required. EVIDENCE: A recent annual development plan for the service was available for inspection. This should be further developed to include other monitoring systems for the service e.g. maintenance and environmental plans to ensure that quality service continues to be provided. Service users have had the opportunity to complete satisfaction questionnaires in respect of activities and meals. Manor Lodge Version 1.10 Page 19 A sample of service users’ records of monies held by the home was inspected. These were up to date and balanced with the sum recorded. Staff receive informal supervision. The manager reported that staff do receive supervision if there was an ‘issue’ to discuss. There needs to be regular staff one to one planned staff supervision. Supervision records need to be available for inspection. The registered person should examine ways of providing appropriate suitable storage for this documentation within the home. In regard to the size of the care home there needs to be a facility in which documentation can be accessed/copied (particularly ‘out of hours’) by appropriate persons, i.e. hospital staff, and GP. This was discussed with the registered manager. The home needs appropriate facilities for communication by facsimile transmission. The registered person needs to record a written report on the conduct of the care home following monthly unannounced visits to the home. The position of the medication cupboard in the office needs moving to minimise the risk of injury. The manager reported that this was planned. Requirements following a Local Authority fire service inspection need to be actioned by the registered person. The fire risk assessment needs further development. This is a previous requirement. There needs to be evidence that all staff have participated in a fire drill at least twice a year. The last recorded fire drill was 10/3/04. The manager informed the inspector that a fire drill took place in Oct/Nov 2004. Recorded evidence of this needs to be supplied to the Commission. Manor Lodge Version 1.10 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x 3 x 3 STAFFING Standard No Score 27 2 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 x 3 x x 2 x x 1 2 2 Manor Lodge Version 1.10 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5(1)(2) Requirement The service user guide needs to be supplied to each service user. It needs to be recorded in the care plan if a service user does not want a copy of this documentation (or if unable to make this decision) Timescale of 1/1/05 not met.. Guidance for staff action to meet service users identified health needs, (such as significant weight gain) need to be recorded. It needs to be recorded in service users care plans if they do not wish to wear a prescribed hearing aid. There needs to be evidence that where appropriate (unless impracticable to carry out such consultation) service users participate in the review of their care plan. The door of a washing machine needs repair. The supranumeray hours of the manager, needs further review, so that she can fully carry out the managerial role, which includes staff supervision, and the staff training role that she Version 1.10 Timescale for action 1/8/05 2. 8 12(1)(2) 13 1/7/05 3. 7 12(1)(2) 1/7/05 4. 7 15(c)(d) 1/8/05 5. 6. 19 27 23 18 1/6/05 1/8/05 Manor Lodge Page 22 7. 33 26(1)(2) (3)(4)(5) 8. 36 18(2) 9. 37 16(2)(ii) 10. 11. 12. 38 38 38 18, 23(4) 13(4)23 812(1)13 (3)(4)18( 1) (a)(c) 13. 38 13(4) 18,23 has taken on. There needs to be a review of staffing needs at peak times. The registered person needs to record a written report on the conduct of the care home following monthly unannounced visits to the home. There needs to be regular staff one to one planned staff supervision. Supervision records need to be available for inspection. (Timescale 1/12/04 not met). The registered person having regard to the size of the care home needs appropriate facilities for communication by facsimile transmission. There needs to be evidence that all staff have participated in a fire drill at least twice a year The medication cupboard needs to be moved to minimise risk of injury. The fire risk assessment needs to be further developed/reviewed to include the hazard and risk of fire in all rooms including residents bedrooms. Requirements following the Local Fire Service inspection need to be met.(Timescale of 1/12/04 not met) Recorded evidence of the Oct/Nov 2004 fire drill needs to be supplied to the Commission 1/8/05 1/8/05 1/9/05 1/7/05 1/7/05 1/8/05 1/8/05 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 3 Good Practice Recommendations A copy of the initial assessment of a prospective residents Version 1.10 Page 23 Manor Lodge 2. 3. 4. 12 15 7 needs, should be recorded in the residents care plan. The registered person should ensure that staff (including the activity worker role) have sufficient time to introduce daily activities. Changes to the recorded menu should be clearly recorded and this information accessible. There should be evidence of a regular review of falls of service users, and the recorded action taken to minimise falls by service users within the home. Manor Lodge Version 1.10 Page 24 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow HA1 1BH 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 Version 1.10 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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