Inspection on 10/10/06 for Manormead Nursing Home

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Manormead Nursing Home 08/09/05

Manormead Nursing Home 03/05/05

Manormead Nursing Home 24/11/04

Manormead Nursing Home 21/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Manormead Nursing Home Manormead Nursing Home Tilford Road Hindhead Surrey GU26 6RA Lead Inspector Mavis Clahar Key Unannounced Inspection 10th October 2006 10:00 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 Manormead Nursing Home DS0000035757.V315428.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. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manormead Nursing Home Address Manormead Nursing Home Tilford Road Hindhead Surrey GU26 6RA 01428 602500 01428 602550 manormeadmanager@jtemail.co.uk mailto:manormeadmanager@jtemail.co.uk www.c-of-e.anglican.co.uk http:/www.c-ofe.anglican.co.uk The Church of England Pensions Board 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) Mrs Judith Alison Williams Care Home 36 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (36) Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: Manormead is owned and operated by the Church of England pensions board, which is a charitable organisation. The board offers a variety of services throughout the country to retired clergy, licensed church workers and their spouses and widows (widowers). Manormead has been established for many years and nursing care is provided in the main building. The majority of accommodation is provided in single rooms, which have en-suite facilities. There are four double/shared rooms. There is a well-maintained garden and a conservatory that is used regularly by service users within the nursing home. The home caters for 36 older people over the age of 65 years. Accommodation is arranged over two floors and there are two lifts. Car parking is available at the front and rear of the building. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit, which forms part of the homes first key inspection to be undertaken by the Commission for Social Care Inspection was undertaken by Mrs Mavis Clahar on the 10th October 2006 and lasted for six and one half (6½) hours: commencing at 09:10.hours and concluding at 15:45 hours. The home is undergoing massive rebuilding which necessitates the front entrance to the home closed. Signs apologising for the inconvenience and directing visitors to the entrance situated to the rear of the home were well positioned. The registered manager was on a day off, but returned to the home as she said she wanted to meet the new inspector. On entering the building through the dining room the inspector was instantly made welcome by the Chef and this positive enthusiasm was reflected by all staff and service users the inspector spoken to during the visit. The first part of the inspection was spent updating the matron about the improvements and changes to the inspection processes under inspecting for better lives. It was during this discussion the registered manager joined the discussion. The inspector commended the manager on the pre inspection questionnaire she compiled to a very high standard, which contained all the information requested. The second part of the inspection was spent with the registered manager, discussing the running of the home, reviewing care workers training files, and sampling some policies. A tour of the home and gardens was conducted; where the inspector took time to spend time with and speak various members of staff, and service users. It was observed that there were no visitors present during the tour, but at the end of the visit whilst signing out, it was noticed that a number of visitors were at the home during the inspection visit. The inspector did not meet with any of these visitors. Time was spent observing the presentation of the meal, care workers and service users interactions and to obtain feedback on the meal, its suitability, taste, texture and amount. Service users commented positively on the meal and on the food served at the home in general. The third part of the visit was spent with the matron reviewing service users files, discussing the nursing process based on a model of nursing, reviewing staff roster, sampling records relating to the safety and welfare of the service users and staff. This was followed by a review of the medication policy and practices and examination of Medication Administration Record (MAR) sheets and the contents of the Control Drugs cupboard, which were found to correspond with the entries in the drug book. No requirements were made on this visit, but it was recommended that the manager persist in obtaining the Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 6 signatures/consent for the care plans of the three service users’ relatives who reside overseas. The inspector would like to thank all the service users, relatives and visiting professionals who completed the questionnaire; service users and staff who made time available in their busy day to speak with the inspector. Lastly the inspector would like to thank the Chef for fluid refreshment throughout the visit. What the service does well: What has improved since the last inspection? The home has instigated regular residents meetings, which are recorded and kept for inspection. Also there is now a system whereby all staff are enabled to sign and date to indicate they have read a policy The additional building is progressing to time. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 7 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. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 8 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 Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 3 6. Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to the service. Significant time and effort is spent ensuring admissions to the home is personal and well managed. Prospective service users and their families are treated with dignity, respect and understanding for the life changing decisions they have to make. There is a high value on responding to the individual service users’ needs for information, reassurance and support. Standard 6 does not apply to this service. EVIDENCE: The Manager said all S/U are pre assessed prior to being admitted. The pre inspection questionnaire is sent out to the GP or Hospital Consultant this is because we admit people from all over the country who are retired Church of England clergy with their partners if they need nursing care or in the care Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 10 sector. They are asked if possible to come in for a period of time prior to making the decision to stay. The matron usually visit service users if it is possible due to distance prior to them being admitted. Once they are in here a full assessment is carried out. The home has their own GP with whom the service users are registered. Service users spoken to said they were from all over the United Kingdom. Some said their GP had a form from the Nursing Home, which the GP used to assess their suitability for the nursing home. They also said it was very good to know that they can be accommodated with their partners. In discussion with the matron who is responsible for care, confirmed what the service users said about being assessed by the GP. This form of assessment is only used for service users who live a long way from the home she said. All other service users are visited and a pre admission assessment takes place in their own homes. Review of random sample of service users assessments indicated that pre admission assessments are undertaken of service users prior to their admission into the home and this assessment is on going. It is from this assessment that the care plans are developed. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 7 8 9 10 Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to the service. The home has a strong ethos of involving service users in all aspects of their life. All service users have a robust care plan. The home has effective systems in place to ensure the care plan is reviewed and updated on a monthly basis and arranges additional reviews when changes take place. Service users are enabled to participate in the development of their care plans, and staff spends time with service users to ensure they understand decisions and actions ensuring that service users health, personal and social care needs are met. The home actively promote the service users right of access to the health and remedial services that they need, both within the home and in the community. Regular appointments are seen as important and there are systems in place to ensure service users are reminded so that appointments are not missed. Records show that the home arranges for health professionals to visit frail service users in the home and provides facilities carry out treatment. Care workers keep a regular check on health aids, to ensure they are in good working order and that each service user has the necessary aids to improve their quality of life, thus ensuring their health care needs are fully met. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 12 The home works to an efficient medication policy supported by procedures and practice guidance. Care workers are aware of and understand the guidance, and quality assurance systems confirm that practice reflects policy. The need to respect service users privacy and dignity when delivering health and personal care is a key principle of the homes aims and objectives. Care workers are aware that this also applies to all areas of the service users’ life. Service users are consulted and can decide which staff member they want to help them with their personal care (or refuse to have help). EVIDENCE: Random review of care plans revealed the home kept detailed individual care plans based on the service user’s assessment of health, physical and social needs. It was further noted that care plans were signed by the service users and in a minority of cases where service users did not have capacity documented evidence was available to show the home is in contact with relative (living overseas) and are awaiting their signatures for these care plans. Appointments dates are entered on to the daily work sheet so that key workers can remind service users of their appointment in good time so as not to rush the service user on the day. In discussion with service users they were able to say whom their General Practitioner (GP) was and that they saw their GP on a regular basis. The recording of GP visits to service users kept by the home supported this information. Moving and handling and risk assessments for service users were completed for service users identified at risk of falls. Pressure area monitoring tools were in place and records of their use were suitably completed. The service offers physiotherapy twice weekly, and service users spoke highly of this service. Comments received from the GP, service users relatives and from service users themselves in the pre inspection questionnaire were commendable especially about the staff and level of care offered by the home. The medication records were reviewed and these were found to be in good order. The Control Medication cupboard and contents were reviewed and all receipts and administrations were recorded correctly. The home employs a pharmacist who visits twice yearly to give guidance and assistance and more often if necessary. In discussion with service users it was apparent they were treated with respect and dignity. One service user said, “this is the best place I could have chosen. I am at home. My family are very pleased that I am enjoying my new home”. Care workers were observed interacting in a dignified manner with service users, friendly but not intrusive. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 13 It was observed that care workers knocked on service users doors and sought permission to enter before doing so. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 12 13 14 15 Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to the service. Service users are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The home has sought the views of the service users and considered their varied interests and abilities when planning the routines of daily living and arranging activities. Routines are very flexible and activity plans are service user focused, regularly reviewed and can be quickly changed to meet the changed needs of the service user. Service users are actively encouraged to maintain contact with their families and friends. Visitors are welcomed any time and facilities are available for them to stay overnight and to have meals with their relatives in the home. Service users can choose to entertain their guests in their bedroom, in any of the lounges and in the garden weather permitting. The practice and attitude of the care workers give service users the opportunity and support to remain independent for as long as they are able. Food is considered to be highly important and meal times considered as a social occasion. The Chef in the home is qualified and experienced in cooking for older people, and is an important member of the care team. The menu is balanced and nutritious. It has a number of healthy option choices and include Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 15 a number of dishes service users requested. Food is served to meet the needs of the service users including those who had swallowing or chewing difficulties EVIDENCE: The Home employs an Activity Coordinator who was not on duty on the day of the visit. However review of documents found records of activities documented such as armchair aerobics, musicals and word games. In discussion with service users they were very commendable on the variety of activities provided by the home. One-service users told the inspector, “ I have one to one sessions with the activities coordinator as I am not able to join in the group activities. The hair dresser will do my hair at a time convenient to my care requirements”. Service users informed the inspector that they attend regular services in the home’s chapel and that a new chapel will be included in the new building being erected to the front of the home. Some service users also attend a bridge club in Hazelmere. The activities coordinator plans outings to the theatre and these are usually well attended. It was evident from discussions with service users that the home provided an atmosphere and lifestyle, which matches their expectations, religious, cultural and social needs. The home’s manager informed the inspector that the home had two guest rooms, which went out of commission with the rebuilding and will be available in Nov.2007 for guests. In the interim a specific bedroom is put aside for the use of guests who are coming from a long way, and there is always a room for guests if their relative is poorly or dying. No cost is incurred for the use of this room. It was evidenced from the visitor’s book and from discussion with service users that the home ensures service users maintain contact with their relatives and friends as they wish. In discussion with service users it was noted that they exercise choice and control over their lives with assistance from care workers as documented in their care plans. Inspection of dry foodstuff was found to be in good order. All foods examined were found to be within their use by dates. Fridge and freezer readings were recorded and available for inspection. The inspector did not sample the lunch, but service users said the food was very good, tasty and the right amount. The inspector observed the presentation of the food was done in a way to stimulate appetite. Lunch was served in the dinning rooms unless a service user requested to have their meals in their bedrooms. Breakfast is served in service users bedrooms. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 16 18 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. Service users and others associated with the home state that they are extremely satisfied with the service provision, feel very safe and well supported by a highly aware organisation. Robust Safeguarding (Protection of Vulnerable Adults) Adults policies are in place to protect the service users. EVIDENCE: Complaints received in the home are logged with their outcomes. This demonstrated that service users and relatives complaints are taken seriously and are dealt with within the homes policy and procedure time frame. The random sample of staff training files and discussion with care workers evidenced that staff are being trained in recognising and reporting acts or suspicion of abuse. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 19 26 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service The home is well maintained and provides comfortable indoor and outdoor facilities. The bedrooms are very well planned with most being for single occupancy. However, there are some double bedrooms, which are occupied by wife and husband. The home has a number of communal areas where service users can sit quietly, entertain their guests or actively engage with other service users. EVIDENCE: At present there is building work being undertaken to the front of the home. Some temporary modification to the entrance of the home had to be made, and this necessitates entry to the home being via the dinning room. Service users spoken to said they did not find this a problem. Environmental health and health and safety risk assessments have been completed. The carpets to the front of the home have not been replaced and this will be done at the same Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 18 time as the carpeting of the new additions to the home. Generally the home’s décor is of a good standard. The home provides nurse call systems, adapted toilets and bathrooms hoists and grab and hand rails which meet the assessed health and social care needs of the service users. There are a number of quiet areas where service users can sit or entertain their guest in peace and quiet. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30. Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to the service Skilled, competent staff met Service users needs. The number of staff on duty was sufficient to meet service users’ needs and service users said they were very happy with the care and facilities the home provided. EVIDENCE: Review of the duty roster revealed that staff present on the day of the visit matched staff documented on the roster. The staff mix of trained nurses, care assistants and domestic workers was sufficient to meet the needs of the service users and to keep the home clean and tidy. The manager informed the inspector that all Sisters attend the Surrey course on Safeguarding Adults. A consultant trainer is employed to come in and train all other staff on recognising and reporting actual or suspected adult abuse three to four times per year. The homes has a video on abuse awareness which staff are encouraged to view and sign to say that they have seen it. The home is actively encouraging all STAFF including domestic staff and volunteers to complete the abuse course. The nursing sisters, care workers and domestic staff supported this in discussions with them. This was further evidenced in their records of training kept on file. It was also noted that the home has achieved 60 of care staff with National Vocational Qualification (NVQ) of Level 2 and above, and 68 of staff appointed First Aiders. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 20 The home has a robust selection and staff recruitment policy, which is based on the home’s equal opportunities policy. All staff including voluntary staff are Prevention of Vulnerable Adults (POVA) and Criminal Record Bureau (CRB) checked prior to commencing work at the home. All newly appointed staff follow the home’s policy and procedure on induction, shadowing and end of induction period interview. The manager informed the inspector that all carers/members of staff must have a current Clear CRB prior to being employed at the home Staff are supervised every two months with full appraisal once per year. This is documented and kept in their personal files, and is available for inspection. Identified learning needs to meet the assessed needs of the service users are dealt with as soon as they arise. Appraisal is delegated down so that Sisters and Registered General Nurses (RGN) are trained to do appraisals with junior care workers. Training and development schedules were reviewed and it was evidenced that training is ongoing and covers current issues related to the care of the service users. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38. Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to the service The manager has the experience to run the home and works to continuously improve services and provide an increased quality of life for the service users and meets the home’s stated aims and objectives. Records are clearly written and up to date; the quality assurance system confirms that the findings from risk assessments have been actioned. There is a strong ethos of being open and transparent in all areas of running the home. The views of the service users and staff are actively sought and actioned in the running of the home. The home does not become involved with service users finance. The service provides training on health and safety issues for all staff and service users health, safety and welfare are promoted and protected. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 22 EVIDENCE: 33. The registered manager has demonstrated that she has kept herself up to date by regularly attending courses designed to improve her management skills and thereby protect the service users and care staff working at the home. In discussion with the manager it was evident she was knowledgeable about the care needs of the service users and the training needs of the care staff to meet the identified needs of the service users. There are clear lines of accountability within the home; each member of staff spoken to on the day of the visit was clear about their role and responsibilities. The home operates a quality audit systems by which the views of service users, stakeholders and staff are sought in order to improve services to service users. Also the responsible individual carries out a monthly audit inspection and copies are on record for inspection. Commission for Social Care Inspection (CSCI) received a good number of replies to the pre inspection questionnaires from service users, their relatives, professionals involved with the home and from visitors to the home, which were all positive in their comments about the running of the home, the care they and their relatives received. The caring attitude and approachability of staff was highly commended. The home has sound policy and procedure to ensure that no one employed by the charity will become involved in any aspect of service users finance. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day of the visit was properly maintained. Records indicated that the fire drills, fire alarm, water temperature, fridge and freezer readings were regularly checked and recorded. Random sample of care workers records indicated that regular mandatory and other relevant training were carried out by care workers on a regular basis to protect service users health, welfare and safety. The registered manager has recently completed the five days Institute of Health and Safety course. In discussion with care workers it was good to hear that they had an understanding of, and implementation of appropriate procedures to safeguard service users. They also spoke about their understanding of promoting safe working practices based on their health and safety training. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 23 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 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 X X 4 Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations The registered manager to continue to pursue the signatures of the agreeing relatives who reside overseas so that the home has a record of their agreement to the care as documented on their relatives care plans. Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Manormead Nursing Home DS0000035757.V315428.R01.S.doc Version 5.2 Page 26 - 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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