Inspection on 08/11/05 for St Catherine`s Manor

This inspection was carried out on 8th November 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 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 Unannounced Inspection 8th November 2005 09:00 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.V266259.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. St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 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.V266259.R01.S.doc Version 5.0 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. 23rd May 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 ensuite 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 Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and the second inspection to be undertaken in The Commission for Social Care Inspection year 2005/2006. Mary Williamson The Lead inspector for the service undertook. The Registered Home Manager Mrs. Susan Haslam was present throughout the inspection. There were thirty service users, one qualified nurse, six carers, four ancillary staff, and the hairdresser present in the home during the visit. Some of the service users were sitting in the lounge reading their newspapers and some were watching television. One service user stated that he liked TV and was looking forward to the Remberance Day Ceremony that weekend. There was an activity session taking place in the dining room and the hairdresser was also visiting the home. A tour of the premises was undertaken and records relating to the care of the service users and the management of the home were sampled. Staff were seen to be respectful and professional in their approach. Several service users stated that they were very satisfied with the care they receive. Lunch was appetising and several service users were very complimentary about the catering in the home. Some staff were offering sensitive support to service users who required help with feeding. The inspector would like to thank the manager, staff, and service users for their hospitality and positive input to the inspection process. What the service does well: The home provides good quality nursing care to service users as identified in individual care plans. Individual and communal accommodation is well maintained and decorated to a good standard. The programme of refurbishment allows for rooms to be redecorated after vacation. The catering arrangements are good and meet the individual and collective dietary needs of the service users. St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Catherine`s Manor DS0000017640.V266259.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 St Catherine`s Manor DS0000017640.V266259.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): These standards remain unchanged. Please see the previous inspection report dated 23rd may 2005. EVIDENCE: St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, and 10. Appropriate arrangements are in place to ensure that personal and health care needs are met in a caring and dignified manner. EVIDENCE: Individual care plans are in place and three were sampled during the inspection. These care plans contain detailed information of the care provided and the procedures to be followed. The care plans are written by the senior care team, with input from the service users whenever possible. Information from relatives, pre- admission assessment, and reports from other specialists are also included in the care planning process. The service user or their designated representative signs these plans. They are well maintained and reviewed on a regular basis. Risk assessments are also in place and include frequency of falls, nutrition, Waterlow scores, and moving and handling. Staff were seen to respect the privacy and dignity of service users by knocking on bedroom doors prior to entering. They were observed to address service users in a positive and respectful way. Screens are provided in shared rooms. St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 Page 10 The home has a policy in place with regard to privacy and dignity of service users and the manager demonstrated that all staff receive training in this during their induction training. All the service users are registered with a local GP, and two service users have retained their own GP. There is also support from the district nurse, the tissue viability and specialists when required. There is a visiting chiropodist, dentist and the outside optician service available on a regular basis. The physiotherapist visits every Saturday and also undertakes the moving and handling assessments. The staff manual handling training is also carried out by the physiotherapist. St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, and 15. Service users are supported to participate in the leisure activities programme provided for them. The catering arrangements in the home meet the individual and collective needs of the service users. EVIDENCE: There is an activities programme in place, which is rotated monthly. This is organised by the activities coordinator. Activities include art and craft, aromatherapy, music and movement, general knowledge quiz, bingo, and board games. Some service users prefer to have one to one support and some like to sit and read the daily newspaper. Outside entertainment is provided monthly for example old time music afternoons. Spiritual needs are supported and several local clergy are welcome in the home. There was opportunity to talk with three relatives who were visiting the home during the inspection. They all spoke highly of the care provided and the level of support they receive form the staff team. They also stated that they are kept informed of any change to care and are involved in the inspection process. St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 Page 12 The catering arrangements in the home are very good. The cook has been in post for many years and manages the kitchen professionally and efficiently. All the required documentation in relation to food hygiene and safety are in place. The food offered is appetising, wholesome and nutritious. Special diets are catered for and the cook will provide several alternatives for service users who have poor appetites are dislike a disk on offer. All the service users enjoyed their lunch and were very complimentary about the food. St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 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 the following standard(s): These standards remain unchanged. Please see the previous inspection report dated 23rd May 2005. EVIDENCE: St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 22, 24, 25, and 26. The indoor and outdoor communal facilities meet the service users needs. The standard of cleanliness is good and the home is well maintained. EVIDENCE: The home is well maintained and decorated to a good standard. There is a programme of refurbishment in progress and all rooms are redecorated after vacation. The communal areas of the home include a large lounge and a dining room, which are comfortable and overlook well- maintained gardens and a courtyard. Individual accommodation is offered in single and shared rooms some of which are en-suite. These have been personalised to reflect individual personalities. The home was clean and odour free with the exception of one bedroom which had malodour. There is an infection control policy in place and all staff have training in these policies during their induction period. St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 Page 15 Arrangements are in place for the collection of clinical waste. There are ample bathing and toilet facilities situated throughout the home. Some of these have been adapted to meet the mobility needs of the service users. There are grab rails, call bells, hoists and wheelchairs also in use to meet mobility needs. St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 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 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, and 30. The duty rota indicated that the skill mix of the staff on duty meets the assessed needs of the service users. The recruitment process promotes the safety of service users. EVIDENCE: The staff duty rota was seen and the skill mix of staff was adequate to meet the needs of the service users. There was one qualified nurse, six carers, one cleaner, one laundry assistant, one cook, and a maintenance person on duty during the inspection. There are four staff with an NVQ level 2 and three staff with an NVQ level 3 current working in the home. All staff receive induction training and foundation training follows this. The recruitment procedure in place safeguards the service users living in the home. Staff employment files sampled included all the required documentation. All staff are in possession of a job description and contract of employment. St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 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 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): 31, 32, 36, 37, and 38. The home is efficiently managed and the service users benefit from the expertise of a competent manager. Some minor shortfalls were noted in the standard of record keeping. EVIDENCE: The registered manager is a qualified nurse with several years experience in the provision of care to older people. She holds her registered managers award and is an NVQ assessor. Her leadership skills and experience promotes an open and inclusive atmosphere in the home. Staff confirmed that they receive regular formal supervision. This was evident in staff employment files. St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 Page 18 The standard of record keeping is generally good and records seen included care plans, risk assessments, duty rotas, staff employment records and menus. There was however a shortfall in the recording of fluid balance and turning charts, as four of these were seen and no entries had been recorded since the 07/11/05. The health and safety policies and procedures promote the safety of the service users living in the home. The fire safety records and the accident records were seen and are well maintained. Staff have regular training in manual handling, first aid, food hygiene, fire safety, and COSHH. St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 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 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 3 2 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 X X X 3 2 3 St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? NO 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 26 Regulation 16(k) Requirement The registered person must ensure that all parts of the care home are kept free from offensive odours. The registered person must ensure that records maintained in the care home are kept up to date to include fluid balance charts. Timescale for action 21/12/05 2 37 17(3)(b) 21/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 Page 21 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 St Catherine`s Manor DS0000017640.V266259.R01.S.doc Version 5.0 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. 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