Inspection on 06/09/05 for Manor Lodge

This inspection was carried out on 6th 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 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 04/04/05

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 6 September 2005 11.15am 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 G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Manor Lodge Address 32-34 Manor Road Harrow Middlesex HA1 2PD 020 8427 3211 020 8868 8375 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) RMD Enterprises Limited Mrs Laura Fernandes Care Home 16 Category(ies) of OP 16 registration, with number of places Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 04/04/05 Brief Description of the Service: Manor Lodge is a care home providing personal care and accommodation for 16 older people. It is owned by R.M.D Enterprises. The home is located in a quiet residential road, within a few minutes walk from Kenton and central Harrow, where there are numerous shops, restaurants, cafes, banks and other amenities, and facilities including train and bus public transport facilities.. 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. The home has 14 single bedrooms, 4 of which have en-suite facilities. There is one shared bedroom. The care home has a passenger lift. The home has an enclosed well-maintained garden at the rear of the property, which is easily accessible. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Manor Lodge took place throughout 5.75 hours during the day in September 2005. The registered manager was on duty and the registered provider was present for part of the inspection. There was one service user vacancy at the time of the inspection. A partial tour of the premises took place. Care records, resident’s contracts, and staff personnel records were among a variety of records inspected. Eight residents, some staff, and three visitors kindly spoke to the inspector prior and/or during the inspection. Observation of staff and resident interaction also took place. 17 National Minimum Standards for Older Persons were inspected. Requirements from the previous inspection were assessed. What the service does well: What has improved since the last inspection? The home has met the majority of requirements, and recommendations following the previous inspection. The variety of daily activities, and entertainments has been further developed since the last inspection, with more choice being offered. Records confirmed that there was involvement from residents, and relatives/significant others in the review of service user plans. Appropriate staff training has taken place since the last inspection, and some staff are enrolled to commence NVQ care level 2 and 3 courses. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 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 G62-G11 S17549 Manor Ldg v234238 060905 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 G62-G11 S17549 Manor Ldg v234238 060905 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) 2 and 3 Arrangements are in place to ensure that residents have a written contract/statement of terms and conditions. All residents have their needs assessed prior to moving into the care home, and during the trial period to ensure that the service can meet prospective residents’ needs. EVIDENCE: A sample of records inspected informed the inspector that residents have a statement of terms and conditions/contract. This documentation incorporated required information, and included overall care and the services provided, and a record of additional services to be paid for over and above those included in the fees. The fees payable and information in regard to cost rises were recorded. Residents (and/or relatives, significant others), and the provider had signed the sample of contracts inspected. Local authority purchasing placement agreements were also available for inspection. The home has an admission procedure. The registered manager and the provider assess prospective resident’s needs. A resident, and a visitor confirmed that the manager had visited the prospective resident’s home prior Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 9 to their admission. Completed assessment information in regard to prospective residents was available for inspection. This included assessment of resident’s personal care needs, dietary needs, healthcare needs, and their mobility needs. Records informed the inspector that residents referred by purchasing authorities, also receive assessment of their needs from a care manager of the relevant local authority. Residents spoke of having visited the care home with relatives/significant others prior to moving in; others gave reasons as to why they had not visited the home. One resident reported that she had not wished to visit the care home before her admission. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.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 and 8 Residents all have an individual plan of care. Arrangements are in place to ensure that resident’s health and personal care needs are met, EVIDENCE: All the residents have an individual plan of care. A sample of three care plans was inspected. This documentation informed the inspector that resident’s particular needs were assessed, and that staff action/guidance to meet these needs was recorded. A procedure for the review of resident’s care plans was displayed. There was recorded evidence that the care plans are regularly reviewed. There is a monthly review, and a more comprehensive six monthly review. Dates of planned care plan reviews were recorded. Records confirmed that there was involvement from residents, and relatives/significant others in the review of these care plans. The home has a pressure sore policy, and records confirmed that resident’s have an individual risk assessment in regard to their risk of pressure sores. The registered manager reported that no residents have a pressure sore. Records, and residents confirmed that residents are registered with a GP and that they have access to appropriate healthcare resources including optician Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 11 services, chiropody services, and dental services. Records confirmed that district nurses provided care as, and when required by residents. Care plan documentation confirmed that a resident had recently received advice, and support from an occupational therapist. Records informed the inspector that residents receive risk assessment in regard to falls, and the registered manager regularly reviews falls by residents within the care home. This review should be further developed to record action taken to minimise the risk of the resident falling again. There needs to be further development in regard to staff guidance in managing risks, and behaviours from residents that might challenge the service. This was discussed with the registered manager. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.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) 12,13 and 15 Arrangements are in place to ensure that residents have the opportunity to participate in varied preferred activities Residents are supported in maintaining contact with relatives and significant others. Meals provided are varied and wholesome. EVIDENCE: There has been progress in the provision of varied leisure, and social activities for residents since the last inspection. Residents participate in a variety of daily activities. Records have been developed to ensure that individual resident’s daily activities are documented. Staff should ensure that these records are kept up to date. Recorded activities included exercises, manicures, skittles, bingo, listening to the radio and watching television. The registered manager informed the inspector that another television, which will be more accessible to residents, is going to be shortly installed in the sitting room. A resident and a visitor spoke of residents participating in a day out to a local country park area, and of attending a barbeque. A piano player played a variety of tunes during the inspection, residents were observed to participate by singing and were judged to enjoy this weekly activity. . A visitor reported that there were several activities within the care home during festive times in the year. Records informed the inspector that residents had had the opportunity to complete ‘preferred’ activity questionnaires. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 13 Visitors spoke of being able to visit at anytime, and reported that staff were welcoming. Residents have the opportunity to receive visitors in their bedroom or in a ‘quiet’ room within the care home. A resident spoke of going out with relatives, and records confirmed that a resident regularly went out to lunch with their relatives. Records, and residents confirmed that they receive regular hairdressing appointments. Several residents were having their hair ‘done’ during the inspection. Residents spoke of enjoying the meals provided. The menu was displayed in the sitting room. The menu for the day was recorded on a board in the communal area. Drinks were provided regularly to residents during the unannounced inspection. Lunch was unhurried. The registered manager was cooking lunch at the time of the inspection. She and the registered person reported that recruitment in regards to a cook was ongoing, and that there had been difficulties in recruiting a cook. There was a temporary part time cook, but for three days a week when she was not working, the manager or senior staff cooked. The registered manager informed the inspector that she and the staff who did cooking had received food and hygiene training. Records and the manager confirmed that there was an extra care staff member employed when senior staff cook. The registered person should employ a cook as soon as possible to ensure that there is a cook everyday, and inform the Commission for Social Care Inspection when a cook has been recruited. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 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 Arrangements are in place for handling complaints objectively. Residents are aware of how to complain, and were confident that concerns would be listened too. Policies/procedures are in place to ensure that there is a proper response to any suspicion or allegation of abuse, but required reporting procedures need to followed at all times. EVIDENCE: The complaints procedure was displayed in the sitting room. Copies were also accessible in the service user guide, and in the policy/procedure file. Records confirmed that the complaints procedure had been reviewed in 2005. Feedback from visitors, and residents confirmed that they were aware of how to complain, and reported that the manager was very approachable. There have not been any recorded complaints since the last inspection. The care home has required protection of vulnerable adults policies, and procedures. These include the Local Authority policy. Documentation in regard to adult protection was accessible. The home also has an antiharassment policy, resident’s monies, and whistle blowing policies. The home has information in the resident’s contract in regard to insurance in regard to their valuables. The inspector was informed that there had been some allegations of theft within the home. This was discussed with the registered manager and the provider. Appropriate action had been taken by the registered person and was on-going. Further action was discussed, and the registered person agreed that he would attain this. All allegations of theft need to be reported to the Commission for Social Care Inspection. The registered person needs to review Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 15 and further develop procedures (including reporting and recording procedures) in regard to allegations of theft within the care home. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home is well maintained. The residents are provided with clean comfortable, and safe surroundings. EVIDENCE: A partial tour of the premises took place. The home is well maintained, and has homely features. The front forecourt area of the care home is tidy. The garden is attractive and accessible. The Local Authority fire service inspection that took place in February 2005 confirmed that they were satisfied with the service. The home has a disposal of clinical waste policy. The home was free from offensive odours, clean and airy at the time of the inspection. A part time domestic staff member is employed. The laundry facilities are located away from food storage and food preparation areas. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 17 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 29 Arrangements are in place to ensure that the number and skill mix of staff on duty enable needs of residents to be met. The recruitment procedures include required safeguards to offer protection to people living within the home. EVIDENCE: Two weeks staff rota was available for inspection. There are generally three staff on duty in the morning (including the manager or shift leader), and two staff on duty in the afternoon. There is also a part time domestic staff member and part time cook. It should be identified on the staff rota, which staff member is doing cleaning duties; also the hours of the night staff should be recorded. There are also two wake night staff. Staff, and visitors informed the inspector that there were sufficient staff. A visitor spoke of visiting her relative at varied times of the day. Staff informed the inspector that they were aware of the importance of not leaving residents unattended in the sitting room area. There needs to be recorded procedures in regard to the staff observation of residents in the communal sitting room area, so minimising the risk of falls. Staff were observed to be supporting residents within the sitting room during the inspection. The registered person confirmed that the review of the supernumerary hours of the registered manager would be on going, and that 21 supernumerary hours had been allocated for the manager to carry out non-care duties. Also that delegation of some duties to senior care staff was in progress. The Commission for Social Care Inspection should be kept informed of the progress of this review (and of the recruitment of a cook, see Standard 15). Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 18 The home has recruitment procedures, and an equal opportunities policy. The care home also has a staff disciplinary and grievance procedure, and staff code of conduct. Three staff files were randomly inspected. These contained the required information and documentation. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 19 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, and (36 and 37partially inspected) and 38 There needs to be development in regards to recording the monitoring systems in regard to the quality of the service provided. Arrangements are generally in place to meet the health, safety and welfare needs of residents. EVIDENCE: A visitor kindly informed the inspector that she received an annual satisfaction questionnaire. Residents and visitors confirmed that the manager is very approachable. Policies and procedures are accessible. These should be dated and show evidence of regular review. Care plans are regularly reviewed. A previous requirement in regard to the registered person recording a monthly report on the conduct of the care home needs to be met. This was discussed with the registered person. The registered person informed the inspector that he visits the care home often several times a week. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 20 The registered person informed the inspector that communication by facsimile transmission (a previous requirement) could be access from the provider’s local office. This was discussed with the registered person. He agreed to review the issue of having a fax machine within the care home. The registered manager, and records confirmed that staff supervision had taken place. Development in regard to the recording of staff supervision was discussed with the registered manager and the registered person. Required fire safety checks records were available for inspection. The last recorded fire drill was 3/8/05, staff, and residents participated in this drill. The home has a fire risk assessment, which has recently been reviewed. This should be easily accessible. Fire safety guidelines were displayed. The home has a smoking policy. Records informed the inspector that staff had received fire training. Fridge and freezer temperatures are recorded. Food safety guidelines were accessible to staff. There needs to be a recorded risk assessment in regard to the use of portable fans. The care home has recorded radiator risk assessments. Accident recording needs to be further developed to include staff action to be taken to minimise the risk of the accident occurring. Records inspected confirmed that staff had recently received basic manual handling training and also emergency first aid training. The required health and safety poster was displayed. The employer’s certificate of insurance was displayed, and expires 27/6/06. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 21 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 x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 2 x x 3 3 3 Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 22 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 7 Regulation Reg 12, 13(4) Requirement There needs to be further development in regards to staff guidance in managing risks and behaviours from residents that might challenge the service. All allegations of theft need to be reported to the Commission for Social Care Inspection. The registered person needs to review and further develop procedures (including reporting and recording procedures) in regard to allegations of theft within the care home. There needs to be recorded procedures in regard to staff observation/attendance of residents in the communal sitting room area. The registered person needs to record a written report on the conduct of the care home following monthly unannounced visits to the home.Timescale 01/08/05 not met There needs to be a recorded risk assessment in regard to the use of portable fans. Accident recording needs to be further developed to include staff action to be taken to minimise Timescale for action 1/12/05 2. 18 Reg 37(f) 1/11/05 3. 27 Reg 13(4) 1/12/05 4. 33 Reg 26(1)(2) (3)(4)(5) 1/11/05 5. 6. 38 38 Reg 13(4) Reg 12, 13 1/11/05 1/12/05 Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 23 7. 38 Reg 13(4)23 the risk of the accident occurring. The medication cupboard needs to be moved to minimise risk of injury. Timescale 1/7/05 not met. 1/11/05 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. 2. 3. 4. 5. 6. 7. Refer to Standard 8 12 15 27 33 37 38 Good Practice Recommendations The review of falls within the care home should be further developed to record action taken to minimise the risk of the resident falling again. Staff should ensure that individual activity daily records are kept up to date. The registered person should employ a cook as soon as possible to ensure that there is a cook everyday, and inform the Commission when a cook has been recruited. The CSCI should be kept informed of the on-going review of the registered managers supranumeray hours. Policies and procedures should be dated, and show evidence of regular review. The registered person should review communication facilities, which include having facsimile transmission facilities within the care home. The fire risk assessment should be easily accessible. Manor Lodge G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 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 G62-G11 S17549 Manor Ldg v234238 060905 Stage 4.doc Version 1.40 Page 25 - 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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