Inspection on 08/12/05 for Merlewood Nursing & Residential Home

This inspection was carried out on 8th December 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.

Other inspections for this house

Merlewood Nursing & Residential... 14/09/06

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Springfield House

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Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Merlewood Nursing & Residential Home Merlewood Nursing And Residential Home Hollow Lane Callow Hill Virginia Water Surrey GU25 4LR Lead Inspector Pauline Long Unannounced Inspection 8th December 2005 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 Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 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. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Merlewood Nursing & Residential Home Address Merlewood Nursing And Residential Home Hollow Lane Callow Hill Virginia Water Surrey GU25 4LR 020 7396 6700 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) Elizabeth Finn Homes Ltd Mrs Mary Alice Toulmin Care Home 6 Category(ies) of Old age, not falling within any other category registration, with number (53) of places Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Merlewood is a long established care home, owned and managed by Elizabeth Fin Trust, which is a registered charity. The original building is Victorian and is set in 23 acres of grounds. The home has been redeveloped to provide additional bedrooms and provides residential and nursing care for older people. Accommodation is provided in single bedrooms, all of which benefit from ensuite facilities. There is ample car parking space available. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second Inspection of the CSCI year April 2005- March 2006 and was unannounced. The inspection was carried out by one inspectors and lasted for three hours and a half hours. On the day the service had a homely and welcoming atmosphere and was being prepared for the festive celebrations. Discussions were held with the deputy manager, care staff, several residents and one visitor. Documents sampled, included service users files, care plans, staff records and policies and procedures. A full tour of the home took place. CSCI would like to thank the residents, deputy manager and staff for their hospitality and co-operation during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 6 On the whole recruitment practices are good. However one of the five staff files sampled did not have two references. In order to ensure that the residents are protected, staff must not be employed without having two references. 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. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 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 the following standard(s): 3,5,6 Files sampled evidenced that arrangements were in place to ensure a full needs assessment takes place before any new admission. Comments received from residents and families indicated that were invited to view the home before admission and that they felt the home could meet their needs. The home does not provide for intermediate care. EVIDENCE: Five resident’s files were sampled. All of them had a comprehensive documented assessment of needs, which was carried out by the head of care or a senior nurse. The deputy manager, stated that she would carry out a needs assessment, at the prospective resident’s home and that she would encourage a visit to the care home to provide a further assessment period. Following admission to the home assessment would be ongoing. Residents and a visitor commented that, they were given the opportunity to visit the home before making a decision as to whether or not the home could meet their needs. This home does not provide an intermediate care service. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 9 Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 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 the following standard(s): 7,8,10 The staff had a good understanding of the resident’s health and personal care needs, which were well met on the day. Resident’s and a visitor commented that residents are treated respectfully. EVIDENCE: The residents care plans were comprehensive, and included needs assessments, communication assessments, risk assessments with regard to manual handling, falls and potential risks to pressure areas. There was documentation regarding changes in healthcare needs. All of the files sampled had been regularly reviewed. There were records with regard to the activities and care being given documented on each individual on a daily basis. Whilst the entries on those residents who require residential care were good and provided a holistic 24 hour overview of the residents, the entries relating to those residents who require nursing care were very task oriented. Record keeping was discussed with the deputy manager, who stated that she would discuss this with the manager and care staff. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 11 Through out the inspection process, staff were observed carrying out various aspects of personal care for the residents. This was carried out in a respectful manner, bedroom and bathroom doors were not left open, staff were observed knocking on doors and waiting to be invited in, before entering rooms. Residents commented that the staff are always respectful. A visitor to the home commented that the girls are very good, I did not think my relative would settle here, but he has. A recommendation has been made in respect of reporting and recording. Please refer to page 23 this report. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 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 the following standard(s): 13,15 The meals in the home are good, offering choice and catering for special dietary needs. The home promotes contact with family, friends and the local community. EVIDENCE: Visitors were observed coming and going as they pleased. One visitor commented that, the home had a very welcoming atmosphere, and that they were always warmly received. Residents discussed family visits, and up and coming festive celebrations. Notice boards contained flyers advertising, church services, carol singing and a piano recital. The dining rooms were nicely presented. The food was served up from the each of the dining rooms servery. Staff were observed offering the residents a choice of meal and a drinks. The tables were nicely laid and the food was well presented. Residents made decisions as to where they might sit for lunch and were observed chatting to each other about what they had chosen for lunch. One resident commented that the curry looked nice, but she was looking forward to sausages. In this home the catering is managed by an out side company. The kitchen was clean and well managed, records relating to food hygiene regulations were Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 13 mostly up to date up do date and in good order. However there were some gaps in the recording. This was discussed with the catering manager, who stated that these gaps identified a training need this would be addressed with the individual concerned. The catering company provides comment books for residents to write their comments about the meals, these books are reviewed on a daily basis by the chef, who also speaks with the residents during meal times. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 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 the following standard(s): 16,18 The home has satisfactory policies and procedures and training in place for dealing with the protection of the residents, and for addressing concerns and complaints. EVIDENCE: CSCI have received no complaints about this home since the last inspection. The home has a complaints/compliments folder. There were no records of written complaints being received at the home. The deputy manager explained that in a reasonably short period of time the home has had four managers and that this resulted in many complaints being received at the home. However since the new manager started complaints to the home had decreased greatly. Discussions with the staff group evidenced that they were all aware of the homes Protection of Vulnerable Adults policies and procedures. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 The standard of the environment within this home is good, and meets the needs of the residents, providing an attractive and homely place to live. EVIDENCE: The home is fairly spacious, comfortable and clean, and on the day free from malodours. Resident’s bedrooms were nicely personalised. One resident stated that she preferred to spend time in her bedroom, she liked looking at the garden and the bird table. The main sitting rooms had ample comfortable armchairs, coffee and occasional tables. On the day all of the rooms in the home had a warm and cosy atmosphere, several residents were enjoying morning television. Water temperatures were checked in various rooms through out the home, and were found to be satisfactory. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 16 Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 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 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): 27,29,30 The staffing arrangements in place on the day of inspection were sufficient to meet the needs of the residents. On the whole recruitment practices were satisfactory. EVIDENCE: Staff recruitment is ongoing at the home. Two new members of staff have been recruited since the last inspection. Staff files seen on the day indicated that recruitment and selection procedures were followed in as much as all had Criminal Records Bureau Checks( CRB) and Protection of Vulnerable Adult (POVA) clearance. However one staff file did not have the required two references. There were letters to indicate that the references had been requested, but these were not followed up. There were 2 registered nurses and 8 care staff duty. The dependency levels of the residents on the day indicated that the present staffing ratio was adequate. Discussions were had around staffing levels, particularly around the recent number of regulation 37 notifications received at the CSCI office. The deputy manger has, as requested carried out an investigation and was confident that staffing levels were sufficient, however she agreed that a review of staffing levels would be good practice. Staff talked about their job roles, there was clarity and awareness of the different roles and responsibilities within the home. Staff also discussed the training opportunities in the home. One member of staff spoken with on the Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 18 day had completed NVQ2, the deputy manager stated that other staff are working towards an NVQ qualification. A requirement has been made in respect of staff references. Please refer to page 23 of this report. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 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 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): 32,33,35,38 The home has good leadership, guidance and direction. The staff are aware of their responsibilities to ensure residents receive consistent quality of care. Residents benefit from the ethos and management approach in the home. However comments indicated that the manager is not visible enough. Residents monies are protected. EVIDENCE: The deputy manager was observed as having a very open and professional approach. Comments from staff indicated that there was an atmosphere of openness and respect and that she spent a lot of time “out on the floor”. Residents and staff appeared confident and relaxed in her presence. The staff commented that the manager was not in a position to spend much time talking to the residents. However residents meeting are held on a regular basis, where residents can air their views about this subject. Residents personal account procedures were sampled. All were found to be in order. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 20 Health and safety checks are routinely carried out at the home. All equipment in use on the day of inspection was properly maintained. Records evidenced that water temperatures, fire drills and fire bells were regularly checked. Through out the inspection, service, staff and resident’s records were sampled. All were up to date and accurate. Residents records are stored on the homes computer system, which all care staff have access to. Hard copies of daily records are also kept to enable ease of use. All records were stored securely and confidentially. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 3 3 3 Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 22 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 OP29 Regulation 19 Requirement The registered person(s) must ensure that all staff files contain all of the information required in schedule 2 of the Care Homes Regulations 2001. Staff files must contain two references. Timescale for action 08/01/06 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 OP37 Good Practice Recommendations In order to ensure a holistic overview of service users, the home should consider developing the resident’s daily records in order to include service user well- being/illbeing as well as tasks completed. Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 23 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 Merlewood Nursing & Residential Home DS0000065967.V267997.R01.S.doc Version 5.0 Page 24 - 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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