Inspection on 25/01/06 for Sutton Manor Nursing Home

This inspection was carried out on 25th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Sutton Manor Nursing Home 21/11/08

Sutton Manor Nursing Home 23/11/06

Sutton Manor Nursing Home 09/05/05

Sutton Manor Nursing Home 21/02/05

Sutton Manor Nursing Home 21/07/04

Sutton Manor Nursing Home 15/01/04

Sutton Manor Nursing Home 31/07/03

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

CARE HOMES FOR OLDER PEOPLE Sutton Manor Nursing Home Stockbridge Road Sutton Scotney Winchester Hampshire SO21 3JX Lead Inspector Mrs Pat Trim Unannounced Inspection 25th January 2006 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 Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sutton Manor Nursing Home Address Stockbridge Road Sutton Scotney Winchester Hampshire SO21 3JX 01962 760188 01962 761185 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) Mrs Evelyn Mary Cornelius-Reid Mrs Linda Gillum-Webb Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability over 65 years of age of places (38) Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate a maximum of 20 service users who are in need of nursing care The home may accommodate a maximum of 38 service users who are in need of personal care only Staffing must be at or above the following levels 1 qualified nurse and 5 care staff 8:00am to 2:00pm 1 qualified nurse and 3 care staff 2:00pm to 5:00pm 1 qualified nurse and 4 care staff 5:00pm to 8:30pm 1 qualified nurse and 2 care staff 8:30pm to 8:00am The management hours of the registered manager must be supernumerary to the minimum staffing levels. The qualified nurse must not offer a service to service users in accommodation outside of Sutton Manor whilst on duty at the home. 9th May 2005 4. 5. Date of last inspection Brief Description of the Service: Sutton Manor is situated in Sutton Scotney. The home is set within sixty acres of delightful parkland. The home is registered as a care home with up to 20 for nursing out of a total of 38 service users over the age of sixty five, in the categories of old age, not falling within any other category and physical disability. All have en suite facilities, with the exception of one room, which has a private bathroom in an adjacent room. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second statutory inspection for the year 2005/2006 and was unannounced. It was completed in 5.5 hours by one inspector. The focus of the inspection was to assess key standards not assessed on the last inspection and to monitor compliance with the requirements made at that time. For an overview of how the home was meeting the key standards, both reports should be read. During the inspection there was an opportunity to speak with five residents, two visitors and six staff. Information was also obtained from the preinspection questionnaire, completed by the registered manager, comment cards completed by residents and relatives, and a random selection of records and documents. A partial tour of the premises was carried out. Some of the people who lived in the home were asked how they would like to be identified in this report. They chose the title ‘resident’ and this term will be used in this and all future reports. What the service does well: Residents felt they received a good service and that staff respected their right to dignity and privacy. Relationships between residents and staff appeared to be good. Residents said that although they liked some more than others, all staff gave them the support they needed. They were addressed as they wished to be, some liking to be called by their first names, whilst others preferred the use of their title. Residents were confident their needs and wishes were the focus of the day to day running of the home and that staff worked hard to enable them to have a good quality of life. They felt able to speak out about anything they were not happy with and that ‘a word with Linda (the registered manager) and what you want happens – by and large’. The home provides a warm and welcoming environment with lots of areas where residents may sit quietly or socialise. There are extensive grounds that residents said they enjoy walking in. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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 Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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): The key standards were assessed on the last inspection EVIDENCE: Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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): 8, 9 and 10 Health care needs are well monitored, so that residents may be confident they will receive the health care services they need. The administration of medication has been reviewed and current practice ensures residents are protected against the risk of error. The ethos of the home and the guidance and training staff receive enable residents’ rights to privacy, dignity and respect to be upheld. EVIDENCE: Residents said they were able to see their doctor whenever they wished. Some preferred to call the surgery direct, whilst others asked for the home to organise a visit. During the inspection the registered manager was observed contacting local surgeries to arrange two home visits. She also asked for a medical review for one resident. There was evidence that doctors were actively involved in the health care of residents and recorded their involvement on care plans. They signed medication records to confirm the changes they had requested. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 Page 10 Residents also said they were able to have home visits from dentists, chiropodists and opticians. Transport was arranged if they had appointments outside the home and residents said everyone was provided with an escort from the home if they wanted one. Health care needs were also discussed with families, if appropriate. For example, during the inspection the registered manager explained to a relative why a specialist mattress was required for her mother. At the last inspection a requirement was made that medication administration records were consistently signed after each resident had been given his/her medication. The records seen at the time of the inspection had been fully completed and the sister on duty confirmed the procedure required the person administering to sign the record after each medication had been given out. A recommendation to record the medication fridge temperature daily had been implemented. Staff were observed knocking on residents’ doors and waiting for permission to enter. Residents confirmed staff addressed them in the way they wished. Some residents felt that when a relationship had built up between them, they preferred staff to call them by their first name, but others preferred to be addressed by their title and this was done. The registered manager explained that there was a programme to fit locks to bedroom doors and any resident who requested one could have one fitted. Some of the residents said they did not know if they could lock the door, as they had never felt the need to. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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): 13 Residents who have limited mobility would benefit from having more opportunities to go to outside activities. EVIDENCE: There was clear evidence that residents are enabled to maintain relationships within the home, as visitors are welcome at any time and provision has been made to assist with their visit. For example there are rooms provided where they may stay overnight and meals may be ordered. The registered manager said that the home had supported residents wishing to visit families over the Christmas period and had helped to arrange transport when required. Activities are provided within the home and relatives and friends are able to attend. For example, on the day of the inspection a ‘Burns’ lunch was provided with whiskey Mac, haggis and a Scottish piper laid on. Many of the residents had guests attending this lunch. Residents said how much they had enjoyed the lunch and the entertainment, although some decided not to eat haggis and had chosen an alternative. Everyone spoken with was very satisfied with the activities and entertainment provided in the home, but some felt it was difficult for those with mobility problems to go out, as they needed assistance and special transport. Several Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 Page 12 said the home used to provide more opportunities to go out and that this was something they missed and would like to see reintroduced. Staff said they had discussed this and were going to raise it at the next staff meeting. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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): 18 The in house procedure for the protection of vulnerable adults is inaccurate and staff do not have sufficient knowledge of the adult protection procedure to ensure residents are protected from the risk of abuse. EVIDENCE: Staff had some knowledge of adult protection procedures and those who had completed their National Vocational Qualification 3 had received some training. They were aware of the Protection of Vulnerable Adults (POVA) list and that care staff had to be checked to see if they were on it before being employed. They understood their responsibility to report abuse in line with the whistle blowing procedure but were unsure of who would take the lead role in coordinating an investigation into an allegation of abuse. The in house policy and procedure did not accurately reflect the guidance in the Hampshire adult protection procedure. The home had a copy of Hampshire’s adult protection procedure. The registered manager said she had already identified the need for further adult protection training and was going to arrange some for this year. She agreed to review the procedure to make sure it followed the Hampshire adult protection procedure. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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): 26 Adequate systems are in place to ensure residents and staff are protected against the risk of infection. EVIDENCE: The home had a policy and procedure in respect of infection control. This had been regularly reviewed. Staff were able to describe the procedure for dealing with soiled linen, used continence aids and commode pans. Suitable equipment such as disposable gloves and aprons were supplied throughout the home and staff were seen using them when required. Communal toilets had liquid soap, paper towels and disinfecting hand wash provided. The registered manager said staff had attended infection control training and that more was being arranged for this year. Staff confirmed they had attended previous training. A list of those who attended was seen. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 Page 15 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): 28, 29 and 30 Staff are supported and enabled to obtain qualifications that enhance their ability to meet the needs of residents. The development of a robust employment procedure ensures that residents are protected. A better system of monitoring staff training needs would enable the registered manager to provide a training plan that ensures staff are able to maintain and develop their skills. EVIDENCE: The home promotes a culture where staff are supported obtain their National Vocational Qualification (NVQ). The registered manager said that currently 8 staff have NVQ 2, 4 have nearly finished NVQ 3 and 1 was just starting NVQ 3. The registered manager said the home employed 21 care staff so when these staff have completed their course the home will have exceeded the required standard of 50 of staff with an NVQ 2 or above. A requirement had been made at the previous inspection that staff files must contain all the documentation required in Schedule 2 of the Regulations. The administration assistant said she had obtained the missing information and files seen at the time of the inspection contained all the relevant information, such as a copy of the birth certificate and proof of identification. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 Page 16 The registered manager said that part of the recruitment procedure was to obtain a Criminal Records Bureau (CRB) disclosure and the Protection of Vulnerable adults (POVA) check prior to employment, or to obtain a POVA first check and contact the Commission for Social Care Inspection for permission to start the member of staff’s induction. A protocol for monitoring staff before full disclosures were received was seen. A file for a member of staff employed since the last inspection contained both a CRB and POVA check, received prior to employment. The registered manager said she was in the process of identifying current training needs and would then provide an annual training programme. She felt that, in previous years, refresher courses had not been rebooked quickly enough so was going to arrange refresher courses every five months. This would give all staff the opportunity to maintain and develop their skills. She also agreed that the current methods for recording training did not give her the opportunity to easily monitor training needs and was developing a more appropriate format. The pre-inspection questionnaire listed training provided to staff in the previous year. This included basic training such as moving and handling and first aid and training to meet the needs of the service user group, such as bereavement. The registered manager said she was going to arrange more specialist training in the coming year and staff were being asked to identify training needs as part of their appraisal. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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 and 33 The registered manager has extensive experience and knowledge in the care needs of older people, which enable her to assess and meet the needs of the residents living in the home. The current systems in place to audit the quality of the service are not sufficiently developed to enable all residents to give feedback about the service they receive. EVIDENCE: Residents and staff said the registered manager was approachable. Residents, visitors and staff were observed throughout the inspection coming to the office to speak with the registered manager. The registered manager has managed the service for many years and demonstrated extensive knowledge of the needs of the residents. Since the last inspection the she has begun the registered manager’s award. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 Page 18 Residents said the registered manager visited them on a daily basis to make sure they were well and had no problems, but there was no formal system in place to obtain their feedback about the service. Residents’ meetings were not held. Staff said they were able to raise issues through their staff meetings. They could also discuss problems with the sister in charge of the shift or the registered manager. The registered manager said that the provider completed monthly visits to the home and that a written report was made under Regulation 26. She did not receive a copy of this report to keep in the home. A requirement was made that a copy must be kept in the home so that the registered manager is aware of the comments and requirements made by the provider. There was a discussion between the registered manager and inspector about the need to develop a more effective quality audit system so that the provider could demonstrate how the views of the residents impacted on the day-to-day management of the home. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X X Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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 OP18 Regulation 13 Requirement The in house procedure for the protection of vulnerable adults must be reviewed to ensure it complies with the guidance in Hampshire’s adult protection procedure. A copy of the inspection report, carried out by the provider every month under Regulation 26 must be given to the registered manager to keep in the home. Timescale for action 25/04/06 1 33 26 25/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 1 Refer to Standard OP30 OP18 Good Practice Recommendations A system for recording and monitoring staff training should be developed that enables the registered manager to ensure staff training is kept up to date. That further training in adult protection procedures is arranged for all staff. Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Sutton Manor Nursing Home DS0000011650.V279425.R01.S.doc Version 5.1 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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