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Inspection on 08/09/05 for Manormead Nursing Home

Also see our care home review for Manormead Nursing Home for more information

This inspection was carried out on 8th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home offers a pleasant and well-maintained environment, which was clean and hygienic. There was a warm, friendly and open atmosphere in the home. There is a good range of activities in the home organised by an activities coordinator and four service users spoken to were complimentary of this service. One service user stated "Very good and a varied programme". Comments cards received from residents also confirmed that they were satisfied with the activities, which the home provides. On the day of the inspection residents were attending a chapel service and in the afternoon an armchair aerobics session took place, which residents were clearly enjoying. Residents spoken to stated that they were happy with their care. One resident stated the care is "excellent". Other comments received from residents were "This is a wonderful place" and "staff are respectful and kind".

What has improved since the last inspection?

There was one requirement made at the last inspection with regard to the agency staff handbook being updated. This was actioned.

CARE HOMES FOR OLDER PEOPLE Manormead Nursing Home Tilford Road Hindhead Surrey GU26 6RA Lead Inspector Lisa Johnson Announced 08 September 2005 10:00 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. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Manormead Nursing Home Address Tilford Road, Hindhead, Surrey, GU26 6RA 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) 020 7898 1800 The Church of England Pensions Board Mrs Judith Alison Williams CRH Care Home 36 Category(ies) of OP Old age, 36 registration, with number of places Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 03 May 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 varity 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 which have en-suite facilities. There are four double/shared rooms. There is a well maintained garden and a conservatory that is used reguarly by service users within the nursing home. The home caters for 36 older people over the age of 65 years. Accomodation is arranged over two floors and there are two lifts. Car parking is available at the front of the building. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for 2005/2006. The announced inspection was carried out over seven hours by one inspector. The main focus of the inspection was to review any requirements made at the last inspection. A tour of the premises took place. Care plans, policies and procedures and other required documentation was sampled. The inspector spoke to seven residents, two relatives/visitors and six members of staff. A number of comment cards were received from residents; relatives/friends and these comments are reflected in this report. The inspector would like to thank the residents, relatives/staff and staff for their hospitality and cooperation in carrying out this inspection. What the service does well: What has improved since the last inspection? There was one requirement made at the last inspection with regard to the agency staff handbook being updated. This was actioned. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.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. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.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 Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.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) 3 &5 All prospective residents receive a pre-admission assessment. Contracts were completed and are in place. EVIDENCE: It was clear that pre admission assessments are implemented prior to any resident moving in the home with a further assessment being completed on admission. Four individual files were sampled contracts were in place in the form of a statement of terms and conditions and were signed by residents where possible. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 &10 The home demonstrated that detailed individual care plans based on assessment were in place that meets the health and personal needs of residents. Residents were protected by the homes policies and procedures for dealing with medicines. Resident’s privacy and dignity is respected. EVIDENCE: Residents have a key nurse appointed. Comprehensive care plans were in place generated from assessment with reviews updated and record. Four care plans were sampled and found to contain nutritional assessments, moving and handling and risk assessments were completed for residents identified at risk of falls. Pressure area monitoring tools were in place and records were completed for recording personal care. The service is able to offer physiotherapy twice weekly and referrals are made for OT, dietician, and speech therapy when required. The service has access to a local GP, optician, chiropody dentist and audiology. Comments received from the general practioner indicate that the home works in partnership with them. Medication records were sampled and were maintained appropriately. The controlled medications cupboard was examined and recorded correctly a pharmacist visits twice yearly to provide guidance and assistance. Staff were observed to be treating residents with dignity and respect. Residents were Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 10 observed to be receiving relatives and four relatives/visitor comments received confirmed that they are able to visit their relative/friend in private. Comments received from the GP also indicate that they are able to see residents in private. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 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 Residents have the opportunity to exercise their choice in attending a range of leisure and recreational activities. Residents maintain links with family and friends. The home should consider implementing a resident’s forum to increase resident’s consultation and decision making in the home. EVIDENCE: The home provides a range of recreational and on display. An activities coordinator is in place and activities range from armchair aerobics, topical conversation, word games, musicals, and indoor gardening and memory sessions. The home has its own chapel and holds regular services and hairdressing facilities are available. Bible classes are held, a mobile library, shop trolley and shop and PAT dog scheme visit the home. There are opportunities to attend recitals and a bridge club in Haselmere. Occasional outings take place to the cinema and theatre at the time of the inspection a number of residents were attending a chapel service in the morning and taking part in armchair aerobics in the afternoon. Resident’s spoken to and from comments received confirms that residents felt that there are a wide variety of activities and that the activities coordinator provides a good service. Residents maintain links with family and friends and some residents had access to their own telephone and one resident had a computer to maintain links. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 12 There is a friends of Manormead and a newsletter. Two residents spoken to and three comments received indicate that some residents would like to be more involved in decision-making. A recommendation was made that the registered manager should consider implementing residents meetings. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 &18 The home is able to demonstrate that there is an accessible complaint policy in place and that residents and relatives will be listened to. Policies and procedures were in place to ensure that residents are protected from abuse EVIDENCE: An adequate complaint procedure was in place and is accessible to all the residents. There have been four complaints logged since the last inspection, which were responded to adequately. Comments received from residents indicate that they feel safe and were aware of who they could speak to if they had a problem. Residents were assisted in enabling them to vote in the general election. A protection of vulnerable adults and whistle blowing policy were available. The updated local authority procedures have been acquired. One matter that was referred under the local authority procedure has now been resolved. There is one further matter, which has been referred, which is currently being investigated. Staff training records were sampled and it was evident that staff were receiving adequate training. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 14 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, 22 23, 25 & 26 The home is well maintained and provides comfortable indoor and outdoor facilities. Individuals are provided with specialist equipment to maximise independence. Residents live in a safe environment and home is clean and hygienic. EVIDENCE: At present there is building work, which is being undertaken internally and externally to the building, which includes a new kitchen and staff facilities that is due for completion at the end of November 2005, and a new supported housing scheme is being built in the grounds to replace existing buildings. Some temporary modifications to the nursing home have been made. Environmental health and safety risk assessments have been completed. The décor of the home is well maintained. However a requirement has been made that carpets must be replaced in the communal corridors due to them being stained this is to ensure that residents are able to live in a comfortable environment. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 15 The homes provides nurse- call systems, adapted toilets and bathrooms, hoists and grab rails which meet the needs of individuals Water is checked weekly and required certificates for servicing were up-to-date and available. The home was found to be clean and hygienic and free from offensive odours. The temporary mobile kitchen was clean and an environmental health visit had taken place, which was satisfactory. Fire records were sampled and records of equipment, alarms and fire drills were available. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 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, 28, 29 & 30 The staffing levels were adequate to meet the needs of the residents. Staff are supported to undertake training and development to ensure that they are competent to carry out their job. Appropriate recruitment procedures were in place to ensure the safety and protection of the residents. EVIDENCE: The staff duty rota was examined and levels were found to be adequate. The home employs seventeen qualified staff as well as a matron/nurse manager. The home also employs, a day activities coordinator, a part time physiotherapist, ancillary, catering, and maintenance and administrive staff. There is occasional use of agency staff. Training and development schedules were sampled and it was evident that mandatory training for staff was taking place including health and safety, food hygiene and manual handling. Seventy eight percent of care staff have gained certificates in first aid and seventy eight percent of care staff have gained National Vocational Qualifications. Training for qualified staff has included catheterization, venepunctutre and wound care. Staff files were sampled and obtained all the required documentation including numbers of police checks and personal identification numbers for qualified staff. The home operates a foundation course for all new recruits and they are made aware of the General Social Code of conduct. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 17 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, 34,35, 36, 37 & 38 The home has implementing quality assurance system seeking views from residents. Adequate procedures are in place to safeguard resident’s finances. A EVIDENCE: The home has introduced a quality audit questionnaire based on feedback from residents and stakeholders and evidence was sampled. The registered individual carries a quality visit out monthly and copies of reports are maintained. Some residents spoken to were aware of the Commission for Social Care Inspection and views were also received via comment cards and the date of the inspection was displayed on the notice board. One staff member spoken to had a good knowledge of residents needs and demonstrated that she had the relevant skills and knowledge to support one resident who has specialised needs. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 18 The home does not handle any aspect of resident’s finances. The homes business plan was sampled and indicated that the service is financially viable. Insurance certificates were in place The home completes annual appraisals and supervision and two staff members confirmed that they receive supervision sessions. Regular staff meetings are held and minutes were recorded and maintained. A range of policies and procedures were available and were sampled including health and safety, food hygiene, equal opportunities, confidentiality, harassment, bullying, nutrition and risk assessment. Policies and procedures are discussed at staff meetings and are displayed. However a recommendation was made that staff should sign when they have received made aware of and read any new policies and procedures. Fridge and freezer temperatures were recorded daily; control of harmful substance information was available. PACT testing records were in place, lift certificates and equipment servicing records and electrical, water and heating certificates were updated. Accident records were logged. However one incident pertaining to a medication error had been recorded and responded to appropriately. However the Commission for Social Care Inspection had not been notified. An immediate requirement has been made that any event that any event which adversely affects the well being or safety of any resident the Commission of Social Care Inspection must be notified. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 19 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 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 3 x 3 x x 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 3 x x 3 3 3 3 3 2 Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 20 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 38 Regulation 37 Requirement The Commission for Social Care Inspection must be informed of any event which adversly affects the health, well-being or safety of any service user. The registered manager must replace the capets that are stained in the main corridoors to ensure that service users live in a well- maintained and comfortable enviroment. Timescale for action immediate 8/9/05 2. 19 16 3 months 8/12/05 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. Refer to Standard 14 37 Good Practice Recommendations The registered manager should consider implementing residents meetings in the home to assist residents in maintaining choice and control over their lives. The manager should consider implementing a system for staff to sign any new policies and procedures when they have been introduced and read. Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 21 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 Manormead Nursing Home h09 h58 s35757 Manormead v242581 080905 stage 2.doc Version 1.40 Page 22 - 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!