Inspection on 09/05/05 for Sutton Manor Nursing Home

This inspection was carried out on 9th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sutton Manor Nursing Home 21/11/08

Sutton Manor Nursing Home 23/11/06

Sutton Manor Nursing Home 25/01/06

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 Feargal Gallen Unannounced 9 May 2005 10:30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 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 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 CRH 38 Category(ies) of OP- Old Age (38) registration, with number PD(E) - Physical disability - over 65 (38) of places Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate a maximum of 20 service users who are in need of nursing care. 2. The home may accommodate a maximum of 38 service users who are in need of personal care only. 3. 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 4. The management hours of the registered manager must be suplementary to the minimum staffing levels. 5. The qualified nurse must not offer a service to service users in accommodation outside of Sutton Manor whilst on duty at the home. Date of last inspection 21 february 2005 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.Mrs Gillum-Webb is the registered manager and the provider is Mrs Cornelius-Reid, who is the registered provider for two similar establishments in Hampshire and Wiltshire. Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that started at 10.30 a.m. and lasted for 5 .5 hours. The manager was present throughout the inspection. Six service users were spoken to and three members of staff. The care files of the residents and staff files were inspected. What the service does well: What has improved since the last inspection? At the last inspection it was noted that fire alarms were not being tested or records being kept if they were tested. The inspector found that this was now being carried out as well as checks on the emergency lights and fire fighting equipment. The manager expects to start her NVQ 4 in September 2005. Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 Page 6 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 v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 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 standard(s) 3 The home carries out pre-admission assessments very thoroughly. EVIDENCE: The manager informed the inspector that people who are interested in a placement usually contact the home. They then come for a visit to the home and an assessment is then carried out this will include physical needs and moving and handling issues. If it is then decided that the home can accommodate the person further assessments are carried out which include letters from current G.P. that will include current medication, brief medical history and details of current conditions. Instructions for any wound care and specialist equipment that may be required. Three pre-admission assessments were seen on the day of the inspection. Two of the residents spoken to confirmed the process of assessment prior to admission was as the manager described. Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 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 standard(s) 7 and 9 Care plans are designed to reflect the individual need of the resident and continual reviewing and updating is taking place. The practice of administering medication does not always safe guard the residents best interest. EVIDENCE: Four of the service users care plans were inspected. All of the files contained assessments from this the care plans are developed depending on need. These were noted to be reviewed on a monthly basis as a minimum or as needed such as for one resident who had suffered a broken hip their care plan had been altered to take this into account. There is a difference in the amount of recording in the daily notes depending on the need of the resident. Those receiving nursing care have more detailed entries. Those who are in receipt of care only many of whom who are self caring had more social entries in the daily notes. There was evidence that families were involved in the care being delivered as the care plans looked at had been signed by them. The G.P. also signs the care plan. Staff had a good working knowledge of what is included in the residents care plan and residents informed the inspector they were informed about their care and signed to confirmed they agree with the plan. Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 Page 10 There is a medication procedure in place for the receipt, storing, administration and returning medication. The policy for administering medication is not always followed. On the day of the inspection it was noted that several boxes on the recording sheets remained blank rather than having initials in them. This can lead to confusion whether or not a person has received their correct medication. Staff are also not giving an explanation of why medication has not been administered. On examination of the records it was noted that no one staff member was responsible for this. The manager has agreed to address this issue with the nursing staff. Issues of this nature were noted at the last inspection. The medication fridge needs to have the temperature recorded daily rather than weekly. Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 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 standard(s) 12 14 and 15 The activities organised by the home meet the social and cultural needs of the residents living at the home and have control and choice in their life. Residents enjoy a healthy and wholesome menu. EVIDENCE: There are several events organised by the home at different intervals through the year. There are coffee mornings held with different themes held. At the time of the inspection a summer barbeque was being organised and it was being held to a certain theme. Those attending would have to dress in special clothes for the day. The residents spoken to were looking forward to the event. They felt that the activities offered were frequent enough and suitable for their cultural needs. Some of the residents who are receiving care only go out daily to the local area and some even have their own transport. No one felt they had to take part in activities if they did not want to. Staff confirmed they would be offered to join if they declined their wishes were respected. The inspector was invited to join four of the residents for lunch. Which was served in the dinning room. Lunch was served by waiters and waitresses to the residents on silver service. The main course was served on a plate and then residents were offered potatoes and vegetables. The meal was wholesome and residents said this was the standard every day. People could have as much or as little as they wished. The dinning room looked out onto the rear garden of the home that was pleasantly laid to lawn, shrub and flower beds. Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 Page 12 Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 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 standard(s) 16 Residents/families can be secure to know their complaints would be acted upon. EVIDENCE: There is a complaint procedure in place that is clearly visible in the home. This clearly describes how a complaint would be investigated, by whom and timescales on responses. A copy is supplied to each resident on admission to the home. The residents spoken to felt happy that if they ever had a complaint it would be dealt with immediately. Staff also felt that if they ever felt the need to complain they would be happy to approach the management and it would be dealt with fairly. Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 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 standard(s) 19 20 and 24 The home provides residents with a well-maintained and safe environment to live in. There is adequate communal space both indoor and external to the home and bedrooms reflect personal choice. EVIDENCE: The home is maintained to a high standard. Continual decoration takes place in the home. There were no risks to the safety of the residents on the day of the inspection. The grounds of the home are extensive and residents said they enjoy going out into the gardens and not just in the summer months. The resident’s bedrooms are decorated to their colour choice and one residents said we are allowed to choose what we want for our room ‘they want us to be happy’. Many of the rooms contained furniture from British culture of the past. Rooms more than exceed the minimum national standard for space requirements. A nursing bed will be provided by the home if required. This was evidenced in one room that a married couple were sharing. Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The home provides adequate staff numbers to care for the residents. The recruiting of staff is not always carried out in a way that meets current legislation. EVIDENCE: The duty rota was examined and levels of staff remain as per the conditions of registration. Staff and residents felt the staffing levels were sufficient to meet needs. There is always a trained nurse on duty who is supported by a team of carers with different experience and qualifications. Five staff files were examined at they did not contained the information required that should be kept for each member of staff. The manager said she had seen all original documentation for staff but did not keep copies. Staff spoken to did confirm they had brought in their original documentation regarding identity. Copies need to be kept on file for all staff. References had been supplied for all staff and at least one from their previous employer. A recent member of staff did not have a current CRB check carried out before commencing employment. Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38 Financial interests of residents are safeguarded The manager experience will be enhanced by formal management training. The home is aware of it’s responsibilities regarding health and safety. EVIDENCE: The manager hopes to enrol at a college to start her NVQ 4 in September 2005. This has yet to be confirmed. The home does not manage any of the resident’s personal monies. Residents must make their own arrangements for this. Several of the resident’s manage their own money personally. The home will help residents find a suitable solicitor or advocate if required. Fire alarms emergency lights and fire fighting equipment are being tested as required and records of this were seen. All of the rooms in the house and the building as a whole have been risk assessed for health and safety issues and necessary action taken to limit risk. Safety notices were posted around the home. Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 Page 17 Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 4 15 4 COMPLAINTS AND PROTECTION 4 4 x x x 4 x x STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x 3 x x 3 Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 17(1)(a) Requirement The registered manager must ensure that administration records are accuratley maintained for all perscribed medications All files must contain the relevant documentation as per schedule 2. Timescale for action 31/07/05 2. 29 19 sch 31/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Sutton Manor Nursing Home v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 Page 20 Commission for Social Care Inspection 4 Floor, Overline House Blechynden Terrace Southampton Hampshire 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 v235866 h54 s11650 sutton manor v235866 090505 final.doc Version 1.30 Page 21 - 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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