Inspection on 29/10/07 for The Manor House

This inspection was carried out on 29th October 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

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Manor House Church Road Windsor SL4 2JW Lead Inspector Kate Harrison Unannounced Inspection 29th October 2007 10:45 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 The Manor House DS0000070091.V347087.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. The Manor House DS0000070091.V347087.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Address Church Road Windsor SL4 2JW 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) 01753 832920 01753 830530 manorhouse@southerncrosshealthcare.co.uk Southern Cross OPCO Ltd Mrs Shanaaz Mohamad Care Home 62 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places The Manor House DS0000070091.V347087.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE). The maximum number of service users to be accommodated is 62. Date of last inspection This is the first inspection visit. Brief Description of the Service: The Manor House Care Centre is a purpose build care home with nursing provided by Ashbourne Senior Living, part of the Southern Cross Healthcare Group, and was opened in June 2007. It is situated in Old Windsor, in a quiet location at the end of a residential road, and has secluded gardens with views of the river Thames. It is a three-storey building with communal and private areas on each floor. There are 60 private rooms, all with en-suite shower facilities, seven communal toilets, five communal bathrooms with assisted facilities, three dining areas and four lounges. There is a hairdressing room, three library/quiet rooms, a laundry room and a kitchen, and there is lift access to the upper floors. All areas are wheelchair accessible, and there are carparking facilities to the front. The fees range from £800 to £1,200 per week, and people need to contact the home for more details about fees. The Manor House DS0000070091.V347087.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’, and was the first inspection since the service was registered with us in June 2007. We arrived at the service at 10.30 hours and the inspection lasted for 6 hours. This inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that we had received about the home since the last inspection. We saw most areas of the home and looked at records and documents relating to the care of the people living at there. There were 19 individuals living at the home at the time of the inspection visit. We asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires we sent out, and their views are included in this report. We looked at how the service was meeting the standards set by the government and in this report made judgements about the outcomes for people living at the home. From our observations and information seen, this service is able to care for people with physical difficulties. At present all the people living at the home come from the same background, and the home would be able to provide for individuals from differing cultural and religious backgrounds. What the service does well: The building is new, well maintained and safe, and is situated in a tranquil place with relaxing views. The gardens are good, with enough sitting places for people to appreciate the grounds. The facilities are good, including assisted hydrotherapy bath and hairdressing room. Other treatments are available, including massage, manicure and pedicure, and reiki on request. Aromatherapy and reflexology are available free of charge. Comments from our survey said the home chooses staff well, as they are ‘without exception always smiling, caring and patient’, and that people are looked after in a ‘skilful and compassionate manner’. Newspapers are provided free, and people find this service very useful. The home now has a new minibus to take people out safely. The group Friends of Manor House has started, and will provide support to people living in the home and to relatives, so that they can benefit from a shared experience. People commented that the home’s manager is very able and ‘a very good communicator’. The Manor House DS0000070091.V347087.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. The Manor House DS0000070091.V347087.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 The Manor House DS0000070091.V347087.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): 3 and 6. The home does not provide intermediate care, so this standard does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals have their needs assessed before moving into the home, so they know that the home can meet their needs. EVIDENCE: The registered manager visits individuals after receiving a referral whenever possible, and completes the company’s eight page pre-admission assessment document. The assessment includes risk assessments about health and personal care topics, preferred activities and personal details. A decision is recorded whether to accept or decline the admission depending on the outcome of the assessment, and a letter of confirmation is sent to the individual or to their representative. We saw two individuals with completed pre-admission assessments and care plans, and noted that their needs were being met at the home. Individuals are provided with a personal copy of the service user’s guide, showing the names of the designated carers, and are encouraged to ask if they need additional information about the home. The Manor House DS0000070091.V347087.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team are able to meet the health and personal care needs of individuals, in a caring respectful way. EVIDENCE: The company has produced documentation for the nursing and care staff members to use to record personal, social and health care needs. The documentation is comprehensive and includes the names of the named nurse and key worker, so the individual knows whom to approach for answers to queries. We looked at the documentation for two individuals recently admitted, and found that their health and personal care needs were documented. The staff members had sufficient information from the plans to know what actions to take to meet the needs of the individuals. We saw both individuals, noted that their needs were met and observed staff attending to them in a respectful and skilful way. The documentation includes both a company nutritional risk assessment and the nationally evidenced-based nutritional risk assessment (Malnutrition Universal Screening Tool), and it was noted that when staff members complete The Manor House DS0000070091.V347087.R01.S.doc Version 5.2 Page 10 both it can cause confusion. We recommend that only the MUST be used, as this will give an accurate assessment of an individual’s nutritional state. All of the relatives who responded to our survey said that the staff members ‘always’ have the right skills and experience to look after people properly. One individual living at the home said that the staff members ‘always’ listen and act on what she/he says. On the day of the inspection visit one relative said that the staff members are ‘very good, very caring’, and we saw letters of appreciation from relatives describing the good care shown to individuals. All new staff members receive induction training to the appropriate standards, so that they have a basic understanding of the principles of care. Nobody manages their own medication at the home, and the home has policies and procedures in place to guide staff in the management of medication. There are good systems in place to manage the medication, such as colour coding for different times of the day and regular audits to make sure that medication is managed safely, and all records seen were appropriately completed. The Manor House DS0000070091.V347087.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are treated as individuals, and are supported to be as independent as possible. Their choices are respected and they are supported to be in touch with friends and family. EVIDENCE: The home aims to provide the level of care and support people need so that they can maintain their independence and individuality. The individual and relatives are encouraged to provide background information about the individual’s life, including photographs, so that staff members and the individual can refer meaningfully to past experiences. The activity organiser takes time to get to know people, and uses the information in the activities provided. We observed a session discussing items from the day’s newspaper, and most of the people taking part became engaged and animated at some time during the session. Other people did not take part, preferring to sit or walk about, and staff members were interacting and supporting them in a skilful caring way. Relatives are encouraged to take part in the life of the home, and in comments from our survey state that the home ‘always’ keeps them informed of important issues affecting their relatives. The manager has a weekly slot for The Manor House DS0000070091.V347087.R01.S.doc Version 5.2 Page 12 relatives to come to her to discuss any issues, and has supported the Friends of The Manor group, so that relatives can become involved and feel supported. The home has several dining rooms, and people can choose where they want to eat. Daily menus are printed and laminated, and individuals can choose what they want to eat. The cook goes to see each new arrival, and discusses food preferences, so that any special needs are known. The dining room is well prepared, food is served individually, and people said that the food is very good. Staff members were available to help people manage their food, and were skilful and timely in their interventions, so that lunchtime was a pleasant experience. The home is aware of the individual needs of the people at the home, and tries to plan so that their diverse needs are met and people are treated equally. Some people attend church services, and leaders of different religious denominations come to the home regularly to see others who cannot attend church. All areas of the home are accessible for people using wheelchairs. The Manor House DS0000070091.V347087.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People at the home and their relatives know how to make any complaints known, and know that they will be looked into. People are safeguarded from harm, and staff members know what action to take if necessary. EVIDENCE: People are aware of the home’s complaints procedure through the information in the service user’s guide, and from the procedure displayed in the foyer. The procedure includes timescales for reply, and to whom to go to if an individual is not satisfied with the outcome. No complaints have been received at the home, and we have not received any information concerning a complaint made to the service. The home has a safeguarding policy and procedure to make sure that individuals at the home are safe from abuse, and new staff members receive training on the subject at induction. The local codes of practice are available at the home, and staff members know whom to contact if they need to. The Manor House DS0000070091.V347087.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe well maintained home, that is clean and comfortable. EVIDENCE: The home was newly opened in June 2007, and is situated in a tranquil residential area with countryside views. An area of the garden is secure so that all the people living at the home can use the garden if they choose to. All areas of the home we saw were clean, hygienic and well maintained. A member of staff is responsible for maintenance and has a system in place to respond to any needs. There is a fire safety risk assessment in place, and staff members are trained in fire safety procedures. The first floor is intended to provide accommodation and communal facilities for people with dementia, and the décor is not entirely suitable at present. The manager intends to make the floor user-friendly for people with dementia, so that their daily lives are made less confusing. The Manor House DS0000070091.V347087.R01.S.doc Version 5.2 Page 15 The home’s laundry room is well equipped, and there are policies and procedures in place regarding the control of infection. Automatic disinfection machines are in place to make sure that sanitary equipment is properly cleaned and to improve the control of infection. The Manor House DS0000070091.V347087.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of people living at the home are met by staff who have enough training to meet their needs, and checks have been done to make sure that they are suitable to care for them. EVIDENCE: At the time of the inspection visit there were nineteen people living at the home, and the staff rota shows who is on duty over the 24 hours. Apart from the manager there were three care assistants and one registered nurse to attend to the personal and healthcare needs of the people, and these numbers were adequate at the time to meet the needs of the people at the home. Housekeeping and kitchen staff members were on duty, as well as an administrator. Some people who responded to our questionnaire said that at times there are not enough care staff available and another comment was that staff members were ‘rushed off their feet’. The registered manager should monitor the impact of staffing numbers on the needs of the people living at the home, so that the numbers of care staff available are enough to meet the needs of all the people living at the home. Two staff members hold the National Vocational Qualifications (NVQ) Level 2 in Care, and this does not meet the National Minimum Standards of 50 trained staff. The manager is addressing the situation by arranging training course, and trying to recruit individuals with the qualification. The Manor House DS0000070091.V347087.R01.S.doc Version 5.2 Page 17 The home’s induction programme is at the appropriate standard and includes safeguarding training. All the mandatory training regarding safety for individuals and for staff members has been provided, and other training regarding care is ongoing, including training about dementia. We checked that the home’s recruitment processes are followed, and that all the necessary information about people working at the home is available. The Manor House DS0000070091.V347087.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, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have confidence in the home, because the manager is experienced and skilful, and measures are in place to keep them safe. EVIDENCE: The manager is experienced and skilled, and has 15 years experience of managing care homes. She gained the Registered Manager’s Award in 2003. People who responded to our survey praised her qualities, and comments included ‘excellent’, ‘a good communicator’ and ‘approachable’. There are good systems in place to involve relatives in the running of the home, including Family Celebration Day, and a regular time for relatives to see the manager every week. It is planned to carry out a quality assurance survey to include people living at the home, their relatives, healthcare professionals and others within the next six months. The Manor House DS0000070091.V347087.R01.S.doc Version 5.2 Page 19 No petty cash is kept on behalf of people living at the home, and interest bearing bank accounts are organised for individuals who are not able to manage their own finances. The registered manager is responsible for health and safety at the home, and contracts are in place for the safe upkeep of services and equipment at the home. The home has a health and safety policy statement and provides training for staff members on all safety topics. There are fire risk assessments and evacuation plans in place in the event of a fire. The Manor House DS0000070091.V347087.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 X 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 The Manor House DS0000070091.V347087.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP27 Good Practice Recommendations The registered manager should monitor the impact of staffing numbers on people living at the home, to make sure that the numbers of care staff available are enough at all times to meet their needs. The Manor House DS0000070091.V347087.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 The Manor House DS0000070091.V347087.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. Re-publishing this information is in breach of the terms of use of that website. 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