Inspection on 24/04/07 for Staplehurst Manor Nursing Home

This inspection was carried out on 24th April 2007.

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

Staplehurst Manor Nursing Home 13/11/06

Staplehurst Manor Nursing Home 09/01/06

Staplehurst Manor Nursing Home 28/07/04

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 Staplehurst Manor Nursing Home Staplehurst Manor Frittenden Road Staplehurst Tonbridge Kent TN12 0DG Lead Inspector Wendy Mills Key Unannounced Inspection 24th April 2007 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 Staplehurst Manor Nursing Home DS0000026207.V336901.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. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Staplehurst Manor Nursing Home Address Staplehurst Manor Frittenden Road Staplehurst Tonbridge Kent TN12 0DG 0113 381 6100 01580 890150 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) www.bupa.com BUPA Care Homes (BNH) Limited Louise Mary Foster Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 31 People aged 50 and above who require nursing care by reason of physical disability, terminal illness or older age. To include provision for 6 people aged 40 and over who are terminally ill. 13th November 2006 Date of last inspection Brief Description of the Service: Staplehurst Manor provides both nursing and/or residential care for up to thirty-one residents. The accommodation is provided in a large house on three floors. It stands in its own grounds and is close to the village of Staplehurst. The grounds include a secluded garden and patio area accessible to residents. There is ample car parking at the front of the home. The home is owned and managed by BUPA. All bedrooms are used for single occupancy. Twenty bedrooms have ensuite WC facilities. There is a passenger lift giving access to all floors and a stair lift for four rooms not accessed by the other lift. All rooms used by residents are connected to the call bell system. There is a main line station close by, as well as local shops, a Post Office, Library and Community centre. There is also a nearby herb and garden centre Current fee charges range from £875 to £1100 per week. Additional charges are payable for chiropody, physiotherapy, hairdressing, newspapers and beauty therapies. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit lasted six hours. During this visit we spoke to residents, their relatives and supporters, and staff, to find out what they thought of the home. We made both direct and indirect observation throughout the visit. A tour of the home was made to see if it suits the needs of the residents and is clean, well decorated and safe. We looked at documentation, including care plans, activity records and health and safety records to make sure they are well kept and up-to-date. Finally, there was an in-depth discussion with the registered manager, Mrs Louise Foster Information given to the Commission for Social Care Inspection (CSCI) by the home itself and by other sources, such as, relatives, friends and health and social care professionals, prior to this visit, was also taken into consideration. What the service does well: The residents are well cared for in very pleasant surroundings. The home is set in extensive, well-maintained grounds. The house is itself spacious and tastefully decorated and furnished. There is a welcoming, relaxed, friendly and open atmosphere. Residents, relatives and staff all say that they feel able to talk to the staff or the manager if they have any concerns. There is a good standard of care. Residents and relatives say that the staff are kind and caring. One resident said, “We are terribly well cared for.” The staff are enthusiastic, well trained and well motivated. They say that they enjoy working as a team and have plenty of training. They take pride in the standard of care that they offer. The nutritional services in the home are good. All the residents spoken to said how much they enjoyed their meals and praised the chefs for the trouble that they take to make sure everyone gets a good choice of what to eat. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 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 Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents, their relatives and supporters are provided with the information they need about the home. Appropriate pre-admission assessments are made. This ensures that only those residents whose needs can be met are admitted to the home. EVIDENCE: All residents are provided with a contract or terms and conditions of stay. The service user guide and statement of purpose have been reviewed and new copies of the service user guide are now in the residents’ rooms and in the reception area. Examination of care plans confirmed that new residents are appropriately assessed prior to being offered a place at the home. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents receive good care. They are treated with respect and their dignity is maintained. EVIDENCE: Since the last inspection the care plans have been revised. The current care plans now contain the information needed to tell the staff how to best care for the residents. However, the current care plans are scruffy and it is difficult to find information quickly. The registered providers and the registered manager acknowledge this problem. New care plans, that BUPA call, “personal plans”, have been developed. These new personal plans are soon to be introduced throughout the BUPA homes. The format of these plans is much clearer. Residents and their supporters will be actively involved in the process of completing these plans. BUPA has set a target for the completion of this task for the end of May 2007. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 10 The policies and procedures for the management and administration of medication have been tightened up since the last inspection. There is better recording and less use of abbreviations that could be misunderstood. Risk assessments are in place for those residents who may wish to self medicate. The manager said that there have been no medication errors since the last inspection. Staff training is up-to date and there is a clear commitment, amongst staff, to ensure that best nursing and care practice is generated throughout the home. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 &15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The day-to-day life of the home and the activities offered meets, and sometimes exceeds, the expectations, choices, social and cultural needs of the majority of the residents. More attention to detail is required when satisfying the expectations of supporters of those residents with more complex needs. EVIDENCE: There is a good choice of activities available in the home. The environment offers good opportunities for walks within the grounds, visits to a close by herb centre and countryside and enjoying conversation and relaxation in pleasant surroundings. The home employs activity co-ordinators who lead a variety of past-times, such as board games, reminiscences and music, on a regular basis. There are also visiting entertainers. On the day of this visit, BUPA was celebrating its sixtieth birthday. The home had put on a buffet tea and visiting musicians supplied a very high standard of entertainment. Activities are recorded appropriately. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 12 The home actively involves the local community in its daily life. It supports, and is supported by, local organisations, including the nearby bowls club. The home uses local services, makes local purchases and is well known and respected in the surrounding area. On the day of this visit many local people were visiting to contribute to the BUPA sixtieth birthday celebrations. Residents said that they appreciate the efforts that the home makes in involving them in activities but several said that group activities were, “not their style”, and that they preferred to “Just get on with their own lives and enjoy the very pleasant surroundings”. Some relatives were concerned that those who are more heavily dependent are not getting the attention they need in respect of activities. The home should consider refocusing their efforts in respect of organised activities so that they may spend more time with those residents with greater needs. The care plans identify the preferences of the residents in respect of activities and residents said that they knew that the manager “knows what they like”. On the day of this visit, there was a good, pre-lunch, informal social atmosphere. Each resident was served with the aperitif of his or her choice. The residents said that they really enjoy their gin and tonic/ brandy and ginger/apple juice/fizzy water, etc. at this time of day. However, it was noted that no ice and/or lemon was offered on the day of this visit . The Home should pay more attention to detail when serving pre-lunch drinks, particularly as this is a very important part of each resident’s day. The home manages nutrition well. There is plenty of fresh produce. Fresh fruit and vegetables and meat are purchased locally. There is always a choice of two main meals and the chef is on hand to prepare something different should a resident not like the choices on a particular day. Residents said that they enjoyed their meals and always had plenty to eat. Several said that they also enjoyed the social occasion of mealtimes although a few residents choose to eat in their rooms. The dining room is spacious, light and airy. Tables are set with linen tablecloths and napkins. The dining tables each have a laminated menu, cruet and a small vase of flowers. One of the senior nurses is on duty in the dining room. Residents who needed were given help in a discreet and patient manner. A regular check is kept on the residents’ weight, the amount they eat and their general health. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good policies and procedures handling comments, concerns and complaints. Policies and procedures for the protection of vulnerable adults are sound. This means that the home listens to, and acts upon, the concerns expressed by residents and their supporters. EVIDENCE: There have been two formal complaints since the last inspection. The registered manager dealt appropriately with both complaints. Examination of documentation showed that written apologies were given and that changes in procedures and practice were implemented following the concerns that were raised. However, there was evidence that both staff and the registered manager could have been less defensive in the way they handled these complaints. The registered manager should work to be more proactive. She should make more effort to involve families in improving services. In particular, the home should accept responsibility for errors and learn by their mistakes. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is very pleasant. It is well maintained, spacious, comfortable, welcoming and tastefully decorated. This gives the residents a very pleasant place to live and enjoy their surroundings. It is a place where they can maintain as much independence as possible. EVIDENCE: The home is in a rural location. There are large, pleasant and well-maintained grounds. The communal areas are spacious, airy and tastefully decorated. Most of the carpeting is of good quality, in good condition and the pile is not so deep that it might restrict mobility of some residents. However, some landing carpets are now looking rather tired. The registered manager said that estimates have been obtained for the replacements of flooring in these areas. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 15 Bedrooms are individual and well decorated. Residents have personalised their rooms by bringing in furniture and other items from their own homes. Specialist equipment was all well maintained and stored safely. It was particularly good to note that all wheelchairs were stored discretely, were well maintained and were spotlessly cleaned. The home is commended for its attention to detail in this respect. All areas were clean and sweet smelling on the day of this visit. Whilst infection control in the home is satisfactory at present, the building is old and the layout is not ideal in terms of maintaining cleanliness. The home must remain ever vigilant in using universal precautions and maintaining infection control. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are good and staff morale is high. There is a good system for organising and management of training. This means that a well-motivated and committed staff cares for the residents. EVIDENCE: All files of staff appointed within the last twelve and files showed that appropriate check had been made. There was good evidence that Criminal Records Bureau, (CRB, two checked referenences, any other checked deemed appropriate). A trained nurse takes responsibility fro training and ensures that there is an appropriate training programme that includes both mandatory and specialist training. She also monitors attendance at training sessions and ensures that records are kept up-to-date. Rosters show that there are adequate staffing levels. Inspection of a sample of staff files showed that there is a good range of skills amongst the staff team. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 17 On the day of this visit there were twenty-four people in residence. When all the vacancies for residents are filled there are six members of staff on the morning shift. On the day of this visit the number of staff on the morning shift had been reduced to five to reflect the lower occupancy level. Some staff felt that this had put them under pressure. They thought that it would be better if staffing levels matched dependency levels and not the number of residents. The manager should review this situation. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 18 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an open management culture in the home. The views of residents, their supporters and staff are listened to and acted upon. EVIDENCE: The registered manager has been in post for nearly two years now. She has a wide expedience in nursing and care practice. She is a registered general nurse and a registered children’s nurse. There was good evidence to show that she has maintained her professional update. She is due to complete the registered manager’s award within the next few weeks. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 19 Residents and relatives say that the manager will always follow up any concerns they may have. Staff said that, “Louise does her best”. They said that she has an “open door” policy and that they find her easy to talk to. Regular one-to-one supervision is established for staff. However, the registered manager does not, at present, have one-to-one supervision with her manager. As she is relatively new to the role of registered manager the company should consider providing appropriate supervision to support the development of her management skills. The manager said that she feels well supported by the company and is able to attend area managers meetings. She has good budgetary control and said that she rarely has difficulty in obtaining new equipment for the home. The home maintains good health and safety records and the area manager visits regularly to carry out checks, in accordance with Regulation 26 of The Care Standards Act. No health and safety hazards were noted on the day of this visit. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 20 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 4 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 X X 3 Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 21 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 OP7 Regulation 15 Requirement New personal plans to be completed for all residents. Wherever possible, residents to be actively involved in this process. Relatives, supporters and health and social care professional to be consulted appropriately Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP27 OP32 Good Practice Recommendations Staffing levels should be assessed against the dependency levels of the residents. The company should consider providing one-to-one supervision for the registered manager to help her take a more pro-active and positive approach to the way she handles comments, concerns and complaints. Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Staplehurst Manor Nursing Home DS0000026207.V336901.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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