Inspection on 28/11/06 for St Catherine`s Manor

This inspection was carried out on 28th November 2006.

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 08/11/05

St Catherine`s Manor 23/05/05

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 Catherine`s Manor Portsmouth Road Artington Guildford Surrey GU3 1LJ Lead Inspector Mary Williamson Key Unannounced Inspection 28th November 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Catherine`s Manor Address Portsmouth Road Artington Guildford Surrey GU3 1LJ 01483 531181 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) Mr L Hasham Mrs Susan Frances Haslam Care Home 34 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (34) of places St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. In respect of this home residents may be admitted from the age of 60 YEARS AND OVER Of the 34 residents accommodated, up to 10 may fall within the category DE (E). Of the 34 Residents accommodated, up to one (1) may fall within the category LD and may be under the age of 60 years. 8th November 2005 Date of last inspection 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 users 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. The fees charged range from £525 to £700 per week. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and was undertaken by Mary Williamson who is a Regulation Inspector. The Register Home Manager Susan Haslam was present for most of the inspection. 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. Most of the service users were sitting in the lounge and some service users were being nursed in bed. It was possible to meet with most of the service users and to talk with some of them in more detail than others. It was also possible to meet the staff team and to get some feed back regarding their experiences about working in the home. They were also able to confirm some of the training they had undertaken. Lunch was observed which was served in both the dining room and the lounge in a relaxed atmosphere. The kitchen was visited, and it was possible to discuss nutritional needs of service users with the cook. The inspector prior to the inspection received fourteen relative comment cards. All of these cards had positive feedback regarding the home and the care provided. Fifteen service user feedback questionnaires were also received by the inspector, with positive comments. Staff of relatives supported service users to complete these. The inspector would like to thank the service users and staff team for their hospitality and help during this inspection. What the service does well: The home provides good quality nursing care to service users as outlined in individual care plans. The assessment and care planning process is good resulting in well written, and easy to follow care plans. There is an activities programme in place, which meets toe individual and collective needs of the service users. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 6 The standard of accommodation is good providing service users with a comfortable place to live. The catering arrangements are well organised and the nutritional needs of the service users are being met. The home is well managed with the organisation committed to staff training and development. What has improved since the last inspection? What they could do better: The home continues to provide good quality nursing care as outlined in welldocumented care plans. There are no requirements as an outcome of this inspection. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 4. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. There is adequate information available to prospective service users to help them make a choice regarding the home. Written contracts, and needs assessments are in place. EVIDENCE: The home has a statement of purpose and service user guide in place. This is in the form of an information pack, which is given to all prospective service users and their families on enquiry. This helps prospective service users and their relatives to make an informed choice about living in the home. An updated version was given to the inspector for information. Contracts of occupancy are in place. These were sampled and outline the care to be provided, the type of accommodation offered, the fees paid and the St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 10 method of payment. The service user or their designated representative signs these contracts. One copy is retained on file, and a second copy given to the service user. A full pre admission needs assessment is undertaken by the home manager prior to admission to determine the suitability of the placement. Needs assessments were sampled for WB, FH, and EP. These assessments are detailed, informative and form the basis of individual care plans. Trial visits are encouraged whenever possible. However this is often not possible due to practical reasons in which case relatives make a decision on behalf of prospective service users. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, and 11. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Service users health and medication needs are met with dignity as outlined in individual care plans. EVIDENCE: Individual care plans are in place and care plans for WB, FH, and EP were sampled in detail. These have been written on the basis of the pre admission needs assessment, input from the service user and their family, multidisciplinary reports, and direct observation from staff. These are well maintained, informative and reviewed on a regular basis. Risk assessments are included in the care plans for example, moving and handling, nutrition assessment, Waterlow Score and for the use of bed rails. The manager stated that the home is in the process of computerising care plans and staff will be undertaking training to manage this effectively. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 12 Arrangements in place to meet the service users health care needs are satisfactory. All the service users are registered with a local GP who visits the home on a regular basis. It is possible for service users to retain their own GP whenever possible. There is also support from the district nurse and the tissue viability advisor. Currently there is one service user with a pressure sore and an MRSA infection. The staff team were pleased to share their success in heeling two pressure sores, which were present when the service users were admitted to the home. There is a visiting dentist, chiropodist, and optician who visit the home regularly or by appointment. The physiotherapist visits every Saturday to undertake all the moving and handling assessments on service users and advise on best practice. She also undertakes the entire manual handling training for staff. There is a medication policy in place and all staff who administer medication are familiar with this policy. They also follow The NMC (Nursing and Midwifery Council) Code of Practice. Direct Pharmacy supplies the medication to the home and will also undertake periodic audits. Medication is stored correctly and there is currently no controlled medication in use. Medication recording charts were seen and are well maintained. There is a fridge provided for medication storage, and the temperature maintained and recorded. Privacy and dignity was being respected and staff were observed to address service users in a polite and respectful manner. Staff knock on bedroom doors prior to entering and screens are provided in shared rooms. Service users are assured that at the time of death staff will treat them with sensitivity, and respect their spiritual needs. There is a detailed procedure for staff to follow in such circumstances, and the home can offer relatives unrestricted visiting during this period. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, and 15. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The leisure activities and community participation provided meet service users individual and collective needs. The catering arrangements are satisfactory. EVIDENCE: There is an activities programme in place, which is updated every month. This is organised by the activities coordinator. Activities include art and craft, aromatherapy, music and movement, and general games. There was a good range of Christmas cards and decorations made by the service users on sale in the reception area. There was also a thank you letter on display from Buckingham Palace in recognition for a birthday card made by the service users sent to The Queen to mark her 80th Birthday this year. Outside entertainers provide music sing along sessions monthly. Some service users prefer to have one to one support or wish to spend time alone reading or listening to music. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 14 Two service users stated that they had an enjoyable trip to the coast during the summer. During the inspection there was Holy Communion service taking place in the lounge and the manager stated that various clergy visit the home regularly or by request. Family links are maintained and relatives are welcome in the home at any reasonable time. They are also consulted in the care planning process and kept informed of any change in treatment or care. Fourteen relative comment cards were received by the inspector, all of which contained favourable comments about the home and the care provided there. The kitchen was visited during the inspection, which was clean and well organised. The menus are planned four weekly by the cook with input from service users. Lunch was observed during the inspection, which consisted of shepherd’s pie, a selection of fresh vegetables followed by apple and blackberry pie and custard. Several service users commented on the good standard of the food provided. Special diets are catered for and sensitive support was seen being offered to service users who required help with feeding. It was good to observe that an alternative dish is available to service users to cater for individual likes and choice. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, and 18. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The complaints procedure and abuse awareness policy in place protect service users living in the home. EVIDENCE: The home has a complaints procedure in place and this is also included in the information pack which all service users have access to. Two service users spoken to stated that they have not had to use this procedure. The majority of the service users living in St Catherine’s Manor would require support to make a complaint. There is an abuse awareness policy in place and all staff undertake training in this procedure, which is part of induction training. During discussion with the staff team it was obvious that they are aware of this procedure. There is a copy of Surrey’s Multi Agency Policies and Procedures Safeguarding Vulnerable Adults in place and all senior staff have attended training in these procedures. The manager demonstrated that more update training has been booked for March 2007. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, and 26. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Service users live in a safe and comfortable home where individual and collective facilities meet service user sneeds. EVIDENCE: The home is well maintained and decorated to a good standard. There is ongoing maintenance programme in place and bedrooms are either redecorated or refurbished on vacation. Communal areas include a large lounge overlooking a well- maintained garden. The dining room is also used as the activities room and this overlooks a courtyard where service users can plant bulbs as part of their activities programme. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 17 Individual accommodation is offered in single rooms with three double rooms also in use. Bedrooms are well furnished and there is the opportunity for service users to bring their own possessions and furniture with them into the home. There are ample toilet and bathroom facilities situated throughout the home some of which have been adapted to meet the assessed mobility needs of the service users. The standard of cleanliness throughout the home is good and there are arrangements in place for the collection of clinical waste. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, and 30. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Service users are supported by a competent staff team, and are protected by a robust recruitment procedure. EVIDENCE: The number of staff on duty was sufficient to meet the assessed needs of the service users in the home. This included the manager, two registered nurses, six care support workers, one cook, one cleaner, one laundry assistant, and one university placement student. Staff confirmed that this was an accurate reflection of the average staffing levels in the home. The corporate recruitment procedure in place is robust and protects the service users. Staff employment files were examined and contain all the required documentation to include an application form, two written references, an employment history, and a CRB (Criminal Records Bureau) Disclosure. Currently there are five staff who have an NVQ level 3 and three with an NVQ level 2 in care. All staff undertakes induction training and mandatory training St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 19 in manual handling, fire safety and abuse awareness is undertaken on a yearly basis. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, and 38. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Service users benefit from well managed home, that promotes the health and welfare of all who live and work there. EVIDENCE: The home is well managed by a competent manager who is a qualified nurse. She has several years experience in the provision of care to older people. The manager stated that she is soon to undertake the role of quality assurance coordinator for Care Homes of Distinction and that the organisation is in the process of appointing a replacement manager for the home. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 21 Staff confirmed that the leadership in the home is open and transparent and daily team briefs take place with open discussion and evaluation. Staff also confirmed that they receive regular formal supervision. This is retained in staff files. Annual appraisal is also undertaken and recorded. There is a wide range of policies and procedures relating to health and safety in place, which were sampled throughout the inspection. All staff are familiar with and follow COSHH procedures. Fire safety procedures are in place to include weekly testing of fire alarms, regular fire drills, and annual fire safety training. Accident are recorded and retained on service users files. St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 22 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 3 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 X 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 3 3 3 X 3 X X 3 St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 St Catherine`s Manor DS0000017640.V321809.R01.S.doc Version 5.2 Page 25 - 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. 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