Inspection on 23/05/05 for St Catherine`s Manor

This inspection was carried out on 23rd May 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

St Catherine`s Manor 04/11/08

St Catherine`s Manor 28/11/06

St Catherine`s Manor 08/11/05

St Catherine`s Manor 08/11/04

St Catherine`s Manor 08/07/04

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 St Catherines Manor Portsmouth Road Artington Guildford Surrey GU3 1LJ Lead Inspector Mary Williamson Announced 23 May 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. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Catherines Manor Address Portsmouth Road Artington Guildford Surrey GU3 1LJ 01483 531181 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) Mr L Hasham Mrs Susan Frances Haslam Care Home with Nursing 34 Category(ies) of OP Old Age (34) registration, with number DE(E) Dementia - over 65 (10) of places St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. In respect of this home residents may be admitted from the age of 60 years and over. 2. Of the 34 residents accommodated, up to 10 may fall within the category DE(E). 3. Of the 34 residents accommodated, one (1) may fall within the category LD and may be under the age of 60 years. Date of last inspection 8 November 2004 Brief Description of the Service: St Catherines Manor is a large detached house located on the outskirts of Guildford and provides accommodation with nursing care for up to thirty-four Older People some of whom suffer with dementia. The home is set out on two floors and is comfortably furnished in a homely style. Service ueres bedrooms are tastefully decorated, and contain many personal items. Several have en-suite facilities. There is a large garden with shrubs, hedges,and flowers. Car parking facilities are available at the front of the house and public transport is readily available. A mini bus is available for service users outings. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and the first in the Commission for Social Care Inspection programme year 2005/2006. Mary Williamson who is the lead inspector for the service undertook the inspection. The registered manager Mrs Susan Haslam was present throughout the inspection. Approximately 75 of the service users, eight staff and three visitors were spoken to during the inspection. A selection of comment cards from Care Managers were also given to the inspector. A tour of the premises was undertaken and records relating to the care of the service users and the management of the home were examined. The home was functioning well and all service users were well cared for and relaxed. Some service users were being nursed in bed and the quality of care being provided was good. The interaction between service users and staff was seen to be respectful and positive. The inspector would like to thank the service users, staff and relatives for their helpful and positive approach to the inspection. What the service does well: The home provides good quality nursing care to service users as identified in individual care plans. The interaction between staff and service users is warm, friendly and respectful. Communal and individual accommodation is well maintained and comfortable. The catering arrangements are flexible and take into account individual need and choice. The staffing levels are sufficient for the home to meet individual and collective needs of the current service users. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 6 Social and recreational activities are varied and provided on a regular basis. The organisation and the manager are committed to the training and development of the staff team. What has improved since the last inspection? What they could do better: The home continues to follow detailed care plans outlining individual needs and choice. One care plan must include a risk of the frequency of falls to reduce the number of accidents for a specific service user. The call bell system must be adjusted in one bedroom to promote safety. The lead was stretching from one side of the room to the other creating a potential trip hazard. When fluid balance charts are in place these must be kept up to date. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 7 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. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 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 standard(s) 1,2,3, and 5. Prospective service users and their families are provided with the relevant information necessary to make an informed choice about the home. Individual contracts outline terms and conditions of the home. Trial visits are encouraged following a full needs assessment. EVIDENCE: The home has a statement of purpose and service users guide in place providing prospective service users and their families or designated representative with the information necessary to make an informed decision about living in the home. The manager undertakes a pre admission needs assessment in order to establish if the home can meet the assessed needs of the prospective service user. A selection of these assessments was sampled and the home has its own assessment tool for this purpose. Contracts of terms and conditions of occupancy are in place and outline all the relevant charges and care which is to be provided. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 10 The manager stated that trial visits are encouraged whenever possible which may be for coffee or a meal. Relatives may visit on behalf of the prospective service user if they are unable to do so for themselves. Two visitors explained how that was the case when they were choosing a home for their relative. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 10 Individual care plans are in place, which generally outline service users care needs. There was one care plan, which did not include a frequency of falls assessment, which was relevant to that specific person. The fluid balance charts were not up to date. Appropriate arrangements are in place to ensure that all service users medical care needs being met. Service users privacy is protected and they are treated with respect. EVIDENCE: All the service users have an individual care plan in place, which outlines their care needs. These care plans are written with input from the service users whenever possible, their relatives, information gathered from the pre admission needs assessment and any medical reports available on admission. These are signed by the service user or their designated representative. The care plans are reviewed on a regular basis. The care staff also use daily record charts to record care given. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 12 There was evidence that risk assessments are also carried out, for example moving and handling, risk of developing pressure sores, and nutrition assessments, which are all included in the care plan. It was noted that a frequency of falls assessment was required to monitor a specific situation. Service users have access to appropriate health care services. A GP from the nearby practice visits the home every Wednesday of when required. There is also support from the district nurses, and tissue viability nurse. The service users have access to a dentist, and an optician on a regular basis. The mobile optician also visits every six months. The physiotherapist who visits every Saturday also carries out the moving and handling assessments and training for the staff. Staff were interacting with service users in a positive and respectful way during the inspection. There were seen to address service users politely and explain their actions when giving care. The staff were observed to knock on bedroom and bathroom doors prior to entry. The home has a policy in place with regard to privacy and dignity of service users and staff have training in these procedures during induction training. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 13 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,and15 There was evidence to suggest that service users social and recreational interests are being met. Service users are able to maintain contact with family and friends. Service users diet was appetising and appealing. EVIDENCE: The home employs an activities co-ordinator who organises activities on an individual and group basis. Art and craft, aromatherapy, music and movement, general knowledge quiz, bingo and board games are an example of what is provided. Outside entertainers are also arranged to provide music afternoons at least once every month. Service users spiritual needs are also supported with various clergy made welcome in the home. Relatives and friends are encouraged into the home at any reasonable time. They are involved in the care planning process and informed of any change that take place. Two relatives supported this during the inspection. Relatives also spoke of the inclusive and supportive atmosphere in the home. The menus are planned over a four weekly cycle and changed every six months. The cook and the manager plan the menus with input from the St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 14 service users. Lunch was observed which consisted of chicken casserole, mixed vegetables, and potatoes, followed by lemon meringue pie. This was appetising, nutritious and wholesome. Special diets are catered for, and sensitive support was available for service users who required help with feeding. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, and 18 Service users and their relatives are confident that their complaints will be listened to and acted upon. Systems are in place to protect service users from abuse. EVIDENCE: The home has a complaints procedure in place and this is available to all service users and their families on admission to the home. One relative stated that although she did not have to make a complaint she felt confident that she would be listened to. There is an abuse awareness policy in place and two staff stated that they receive abuse awareness training during their induction training. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20, 21, 22, 24,and 26. The indoor and outdoor communal facilities meet the service user needs. There are sufficient bathrooms and toilets, which have been adapted to meet mobility needs of service uses. The standard of decoration and cleanliness is of a high standard. EVIDENCE: The home is well maintained and decorated to a good standard. Accommodation is offered on two floors, and in single and shared rooms. Service users bedrooms have been personalised to reflect individual personalities. Personal items of furniture can be brought into the home. The communal areas include a large lounge and dining room, which overlook large well-maintained garden and a courtyard. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 17 There are sufficient toilets and bathrooms situated throughout the home some of which have been adapted to meet the mobility needs of the service users. The call bell system needs to be reviewed in one service users bedroom to maintain independence and reduce the risk of accidents. Currently this is stretched across the room and is a potential trip hazard. The laundry facilities are good and personal laundry is included in the terms and conditions of occupancy. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 18 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, 29, and 30 Evidence gathered during the inspection indicated that the skill mix of staff meets the assessed needs of service users. Staff are enthusiastic and committed to caring for the service users. The recruitment process was satisfactory. EVIDENCE: The staff duty rota was examined and confirmed the skill mix of staff, and the amount of staff on duty were adequate to meet the assessed needs of the service users. The manager is committed to the training and development of her staff and records confirmed NVQ training at level 2 and 3 was ongoing. All staff receive induction training, which is then followed by foundation training. Adaptation students from overseas and student nurses from Surrey University are also working in the home. The recruitment procedure is robust and safeguards the service users. Two staff files were examined and all the required employment records were in place. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 37, and 38. Evidence gathered during the inspection indicates that the home is well managed in the best interests of the service user. The standard of record keeping is good and promotes the health and welfare of the service users. EVIDENCE: The registered manager is a qualified nurse with several years experience in the provision of care to older people. She also holds her registered managers award. Her leadership skills and experience promotes an open and inclusive atmosphere in the home. Both service users and relatives stated that they felt well supported by the management structure in the home. The standard of record keeping is good. Records sampled included care plans, risk assessments, staff duty rotas, employment documentation, and menus, which all promote the best interests of the service users. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 20 There is a wide range of health and safety policies and procedures in place and these were viewed throughout the inspection. All staff have training in these procedures, which also includes first aid, fire safety, food hygiene, moving and handling, and COSHH. The manager is committed to the ongoing development of the staff team in health and safety issues. St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x 3 3 2 x 3 x 3 STAFFING Standard No Score 27 3 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 x x x 3 3 St Catherines Manor H58-H09 s17640 St Catherines Manor v219221 230505 Stage 4.doc Version 1.30 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 7 Regulation (15(1) Requirement Service users care plans must include a risk assessnent for the frequency of falls and an action plan for the management of this. The call bell in an individual bedroom must be adjusted to promote safety and independence Timescale for action 30/6/05 2. 22 23(2)(n) .30/6/05 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. 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