CARE HOMES FOR OLDER PEOPLE
Manormead Tilford Road Hindhead Surrey GU26 6RA Lead Inspector
Lisa Johnson Unannounced 3 May 2005 10.30 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. H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Manormead Nursing Home Address Tilford Road Hindhead Surrey GU26 6RA 020 7898 1800 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) The Church of England Pensions Board Mrs Judith Alison Williams Care Home 36 Category(ies) of OP Old Age (36) registration, with number of places H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: old age, persons to be accomodated will be over 65years Date of last inspection 24 November 2004 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, licenced church workers and their spouses and widows(ers). Manormead has been established for many years and nursing care is provided in the main building. The majority of accomodation is provided in single rooms with en-suite facilities with the exception of four double/shared rooms. There is a well maintained garden and a conservatory that is used reguarly by the service users within the nursing home. The homes caters for 36 older people over the ageof 65 years. Accomodation is arranged across two floors and there two lifts. car parking is available. H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This visit was the homes first inspection for the year 2005/2006. This was an unannounced inspection. The first part of the visit consisted of a discussion with the home manager. A tour of the premises took place followed by a discussion with service users living in the home. The inspectors spoke to two members of staff. A number of documents were inspected during the visit; these were the statement of purpose, Service users guide, residents contracts, the homes financial and business plan, the homes complaint policy, medication records including the controlled medications register, care plans, risk assessments and the staff training records. What the service does well:
The home benefits from a staff team who understand the service users and their needs well. Day to day choice was promoted by staff for example offering choices from the homes menu. Two service users spoken to stated that staff are helpful and supportive. Good interaction was observed between staff and residents, the staff were observed to be courteous and respectful. An active timetable for service users was in place, which offered a variety of activities; service users spoke positively about this and one resident said, “I have been asked if there is anything I would like to do”. The environment was of a high standard; bedrooms were personalised with resident’s choice of belongings. Menus in the home were varied, well balanced and the midday meal was nicely presented. Service users confirmed that they were happy with the choices of meals available. Risk assessments for Service Users and environmental issues were very detailed. . H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 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 H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2 & 4 The home makes available quality information about the home and this would help prospective service users to make an informed choice as to whether the home would be suitable place to live. EVIDENCE: The home has recently reviewed and revised both its statement of purpose and service user guide and has provided copies to the Commission For Social Care Inspection. Both documents were detailed in content, well laid out and informative. After discussion with the Home manager and service users, the Service user guide has been made available to them. Each service user in the home has a contact, which states in detail how much it costs to live at the home, what is included and the cost for any other additional services. H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 & 11 At the time of this inspection, the service users personal and healthcare needs were being adequately met. EVIDENCE: Evidence gained from this inspection indicates that each of the standards assessed are being met effectively. A comprehensive care plan is available for each service user, which covered in detail all aspects of health, personal and social care needs. From discussion with staff, care plans are drawn up in consultation with service users, however an information folder, which is in place for agency staff providing details of care requirements for all of the Service Users, needs updating. Risk plans are available for service users who may be at risk of falling. Evidence was available that a service user who may be at risk of pressure sores is stated and appropriate interventions are documented. Records indicated that service users are accessing heath care services and daily notes are in place to record progress. There is an openness and willingness on the part of staff to provide support to service users who are suffering bereavement. This was supported by one service user who’s husband had passed away recently. She talked positively
H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 10 about the extra help and support that she had been receiving from staff. Evidence was seen that the individual wishes regarding death and dying are obtained and recorded in the service users plan. H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 11 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 The home is able to demonstrate that residents are given opportunities for stimulation through leisure and recreational activities. EVIDENCE: Interaction between staff and service users was observed to be very positive. A comprehensive activities timetable is available and a day activities coordinator is in place. On discussion with service users in the home they were happy with the range of activities available. One service user stated, “There is a lot of activities here to do if I want to join in”. There are no restrictions with regard to visitors and local community involvement is encouraged. Lunch was observed being served and the food was of a good quality. One resident stated “Meals are discussed with me and I am able to make a choice from the menu”. The dining room is very pleasant and the mealtime was relaxed. Good interaction was taking place between staff and service users who required support with eating their meal. H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 12 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 & 18 The home has made good progress in being able to demonstrate that service users, relatives and friends views are important and acted upon and that residents are being appropriately protected. EVIDENCE: The home displays the complaints procedure, which has been reviewed and now includes timescales for response to a complaint and that any complaints can be referred to the Commission for Social care Inspection at any time. Evidence was seen that the manager actively follows up any concerns and provides feedbacks regarding the outcomes. There is currently one vulnerable adult investigation in process under the local authority multi-agency procedure. Staff have attended Vulnerable Adult protection training and recruitment policies are adhered to and was evident in staff training records. From observations on this visit, staff were respectful to Service users and this was confirmed by service users who stated that staff are helpful and supportive. H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 & 26 The home meets the assessed standards and provides a good level of accommodation appropriate to the needs of the current residents. EVIDENCE: The home was found be in very good decorative order and was clean and free from offensive odours. Bathrooms and lavatories were of a high standard and accessible. Specialist equipment is available to maximise service users independence. Bedrooms were bright and well ventilated; furnishings were of good quality and decorated with service users personal possessions. Environmental risk plans are in place. It was reported by the manager that the kitchen is shortly to be refurbished. The home has a pleasant, well-maintained garden, which is accessible to the service users in the home. H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 14 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) 29 and 30… The staffing arrangements in place were adequate to meet the needs of the current Service users. The home has made good progress in ensuring that all staff records are available and development of the staff has been given a high priority. EVIDENCE: Staff files contained the relevant information required; a standard checklist is in place. New staff are only confirmed in post following satisfactory criminal record bureau checks. Evidence was available that staff formal supervision takes place every two months. One staff member spoken to confirmed that she is supported and that she receives supervision. Individual staff training records are available, there was evidence that mandatory is taking place. National Vocational Qualifications are supported and sixty percent of the staff have acquired the certificates, a majority of these have obtained a NVQ level three. H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 15 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) 31, 32, 33, 34, 36 &38 The Home was seen to be running well with good management support. The health and safety and welfare of the residents was promoted. EVIDENCE: The home manager is experienced and holds the registered Managers Award. The home is in the process of implementing quality monitoring questioairres to obtain views from service users, relatives and visitors, a copy of these surveys were viewed. The manager has insured that safe working practices are in place, this was evident in staff training files where staff have attended mandatory training such as fire safety, firstaid, food hygiene and moving and handling. Detailed up to date risk assessments are in place H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 x 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 3 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 3 3 3 3 x 3 x 3 H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 17 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 7 Regulation 15(2)(b) Requirement The agency information book detailing care requirements for all of the service users must be updated. Timescale for action 1 month. 3rd June 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 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 H58-H09 s35757 Manormead v224455 030505 Stage 4.doc Version 1.30 Page 19 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
