Inspection on 04/09/07 for The Manse

This inspection was carried out on 4th September 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

The Manse 29/05/08

The Manse 09/05/06

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE The Manse 11 South Norwood Hill South Norwood London SE25 6AA Lead Inspector Mohammad Peerbux Key Unannounced Inspection 4th September 2007 09:10 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 Manse DS0000067467.V349843.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 Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manse Address 11 South Norwood Hill South Norwood London SE25 6AA 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) 020 8771 2832 020 8771 4506 veronica.mccleary@sanctuary-housing.co.uk www.sanctuary-care.co.uk Sanctuary Care Ltd Ms Veronica McCleary Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Manse is granted permission to use Room 7 as one of the registered rooms in the home. Flat 17 (The Manse) is for use as a shared room by the married couple named in correspondence between the Commission and the provider. The provider will inform the Commission when the couple no longer require Flat 17 and it will revert to being a room for single occupancy only. Date of last inspection Brief Description of the Service: The Manse is registered with the Commission for Social Care and Inspection to provide personal care for up to twenty seven older adults. The property is a purpose built residential care home located in the centre of South Norwood close to local shops, eateries and good public transport links. The home shares the site with a sheltered housing scheme, which is also managed by the Registered manager. The home has plenty of communal space, which includes a large lounge/dining room on the ground floor, and much smaller lounge/dinning rooms with kitchenettes attached on the first and second floors. The home has its own laundry room on the first floor, a ground floor office and a garden patio with tables and chairs. The range of weekly fees is between £432 and £518 and this information was gathered on the day of the inspection (04/09/07). The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2007/2008. In writing the report consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. This was the home’s first inspection for the year 2007/08. It took place over eight hours. Some times were spent looking at the policies and procedures, records, talking to some residents, staff and manager. A tour of the building was also carried out. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. What the service does well: What has improved since the last inspection? The main lounge, day rooms on both first and second floor and several bed rooms have been redecorated . The first and second floor day rooms have been also re-carpeted. The Manse DS0000067467.V349843.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. The Manse DS0000067467.V349843.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 Manse DS0000067467.V349843.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home undertakes an assessment of the healthcare needs of residents prior to their admission to ensure that their needs would be met. EVIDENCE: Four residents’ files were sampled at random and they all had a pre-admission assessment carried out. However it was noted that the assessments were not always dated and/or stated who carried them out. The home needs to ensure these are done so that staff are aware of the past and present needs of the residents and who they can contact to clarify any issues to do with the assessments. The manager must also ensure that the assessment of the residents needs is kept under review and is revised at any time when it is necessary to do so having regard to any change of circumstances. The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 9 Intermediate care for rehabilitation and return to the community is not provided by this home. The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 10 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. Each resident has a care plan in place however the care plans do not always cover all their care needs. EVIDENCE: Four residents’ care plans were sampled at random and it was noted they included basic information necessary to deliver the resident’s care but did not cover all the residents’ needs. For example one resident suffers from diabetes and another from hypertension, these needs were not covered in their care plans. This was discussed in depth with the manager and senior support staff during the inspection. The home must ensure that residents’ care plan cover all The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 11 aspects of their health, personal and social care needs and set out in detail the action which needs to be taken by care staff to ensure these are met. There is a key worker system that allows staff to work on a one to one basis and contribute to the care plan for the individual. Care plans are being reviewed and updated however the reviews do not always reflect the needs of the residents. The home must ensure that residents’ plans are reviewed at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. The home actively promotes the residents’ right of access to the health and remedial services that they need, both within the home and in the community. Records show that the home arranges for health professionals to visit residents in the home and provides facilities to carry out treatment. Presently none of the residents have pressure sores. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. However there was some confusion on the stock of medication, which the home received for one resident. The manager was advised to contact the chemist to rectify the situation. Staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms. Residents who were spoken to stated that they are happy with the way that the staff deliver their care and respect their dignity. One resident stated, “I am happy here and the staff look after me well, they are very kind”. Observation of the staff team interacting with the residents showed that the carers were mindful how they addressed residents, and they were seen to be polite and friendly. The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 12 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. Residents are being provided with a range of opportunities for recreational and social activity that is in accord with their social and cultural needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Staff are aware of the need to plan the routines and activities of the home in a way, which meets the choice, and wishes of residents. The home tries to be flexible and attempts to provide a service, which is as individual as possible by using its staff and resources effectively. As far as possible the residents are consulted on how the home can work to provide them with a flexible lifestyle, and to achieve their wishes. The manager stated that three residents go to church on a regular basis and there are also church services in the home for other residents. The home is in the process of employing a part time activities coordinator. The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 13 The home has open visiting arrangements and residents know they can entertain their family and friends in their own room. If they prefer they can use communal areas of the home to talk to visitors. It is clear that the home encourages individuals and groups from the community to visit the home. Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective of the home. Residents have the choice to bring personal possessions with them on admission to the home and are encouraged to keep personal items, which are important to them in their own room. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. Staff are ready to offer assistance in eating where necessary, discreetly, sensitively and individually, while independent eating is encouraged for as long as possible. The cook consults with residents and tries to meet the preferences and suggested dishes when preparing the menu. The menu is incorporated to reflect ethnic minority residents’ choices. The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 14 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. Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. EVIDENCE: The home has a complaints procedure that is conspicuously displayed in the home for all to view. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The current complaints procedure is good and gives a clear step-by-step guide of how to make a complaint. The home is clear when an incident needs to be referred to the Local Authority as part of the local Safeguarding procedures in place. Most of the staff working within the home are fully trained in Safeguarding Adults and know how to respond in the event of an alert. The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet service users’ individual and collective needs in a comfortable and homely way. Residents’ bedroom are personalised to reflect their individual needs, and personalities. Overall the home was decorated to a good standard throughout and appeared to be very comfortable, bright and warm. The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 16 The home is kept clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. However COSHH materials were left unlocked in the laundry and sluice room and this could potentially place residents at risk (see standard 38). The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 17 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. Staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency and to ensure their safety. The home’s recruitment procedures protect the residents through vigorous staff vetting. EVIDENCE: Resident spoken to during the visit all said they were happy with the care provided, they found the staff friendly and helpful. Generally residents have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. The registered manager informed that more than 50 of staff have an NVQ level qualification at level 2. Recruitment procedures seemed appropriate. Four staff files were examined at random and found to contain all the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 18 The home ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The manager is aware that there are some gaps in the training programme. These are being addressed and further training sessions have been arranged. The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home management generally provides guidance and direction to staff to ensure residents receive consistent quality care. There is a good equality monitoring system and this ensures the home is run in a way that is in the best interests of the residents. EVIDENCE: The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 20 The registered manager has the required experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and transparent in all areas of running of the home. She is also aware of current developments both nationally and by CSCI and plans the service accordingly. Effective quality assurance and quality monitoring systems, based on seeking the views of residents, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The registered manager informed that small amounts of money are kept in separate envelopes for each resident with a running balance sheet appropriately maintained for sundries, such as hairdressing costs. A sample of these was seen and was accurate and well maintained. From staff files sampled at random there were evidence that care workers are being supervised on a regular basis. Two health and safety issues arose during this inspection and they are as follows: -COSHH materials were left unlocked in the laundry and sluice room. All COSHH materials must be kept locked in accordance to Control of Substances Hazardous to Health Regulations (COSHH) 1999. -Food products were not covered appropriately and/or not dated to state when they were opened/cooked. The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 21 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 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 X 3 X 3 3 X 2 The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 22 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 OP3 Regulation 14(1) Requirement The home needs to ensure the residents’ needs assessment are dated and signed so that staff are aware of the past and present needs of the residents and who they could contact to clarify any issues to do with the assessments. The manager must ensure that the assessments of residents’ needs are kept under review and are revised at any time when it is necessary to do so having regard to any change of circumstances. The home must ensure that residents’ care plan cover all aspects of their health, personal and social care needs and set out in detail the action which needs to be taken by care staff to ensure these are met. The home must ensure that residents’ plans are reviewed at least once a month, updated to reflect changing needs and current objectives for health and DS0000067467.V349843.R01.S.doc Timescale for action 04/12/07 2. OP3 14(2) 04/12/07 3. OP7 15(1) 04/12/07 4. OP7 15(2) 04/12/07 The Manse Version 5.2 Page 23 personal care, and actioned. 5. OP38 13(4) COSHH materials must be kept locked in accordance to Control of Substances Hazardous to Health Regulations (COSHH) 1999. Food products must be covered appropriately and/or not dated to state when they were opened/cooked. 04/09/07 6. OP38 13(4) 04/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Manse DS0000067467.V349843.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!