Inspection on 09/05/06 for The Manse

This inspection was carried out on 9th May 2006.

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 04/09/07

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 9th May 2006 9:30am 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.V293119.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. The Manse DS0000067467.V293119.R01.S.doc Version 5.1 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 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.V293119.R01.S.doc Version 5.1 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. 5th of December 2005 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 £420 and £493 and this information was gathered on the day of the inspection (09/05/06). The Manse DS0000067467.V293119.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection for the year 2006/07. It was an unannounced inspection and took place over four and half hours. Some times were spent looking at the policies and procedures, talking to staff, manager and to some of the service users. They are all thanked for their time and assistance. A tour of the building was also carried out. Service users spoken to stated that they were happy with the care being provided. Requirements and recommendations from the previous inspection were also discussed with the registered manager. Overall the inspection confirmed that the home provides a good level of care for the service users who live there. What the service does well: What has improved since the last inspection? All staff are now receiving formal documented supervision at least six times a year and the medication administration records are being accurately completed at all times. The Manse DS0000067467.V293119.R01.S.doc Version 5.1 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 Manse DS0000067467.V293119.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 The Manse DS0000067467.V293119.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): 1,2,3 and 6 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Changes are needed to both the Service Users Guide and the Statement of Purpose so that they accurately provide full information about the service. This will provide the correct information to enable people to make informed decision about the home. The home has its own assessment plan to ensure that any new service user’s needs are fully assessed prior to their admission. EVIDENCE: The home has recently been taken over by Sanctuary Care Ltd. The registered manager must amend the statement of purpose and service users guide to reflect this change and update any relevant information in both documents. This is to ensure that prospective service users have the information they need to make an informed choice about where to live. The manager is reminded that the service users guide and the statement of purpose should be kept under The Manse DS0000067467.V293119.R01.S.doc Version 5.1 Page 9 review (by the registered person) and revised should any changes to the service occur. It is also recommended that the service user’s guide is made available in a language and/or format suitable for intended service users. Three service user files were sampled and found that service users have a contract in place. This outlines exactly what services are provided. Some of the contracts are signed by the service users themselves. Service users are only admitted to the home after a full assessment of their needs has been carried out by the home and the Placing Authority for individuals referred through Care Management, involving the prospective service user/recognised representative. Since the last inspection there has been three service users who have been admitted to the home and it was positively noted that they all had a comprehensive needs assessment carried out by the home. The home does not offer intermediate care. The Manse DS0000067467.V293119.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Generally suitable arrangements are in place to ensure that service users’ physical and emotional health care needs are identified, planned for and met. Personal care is carried out in a way that service users prefer so that dignity and choice are maintained. Medication is well managed to maximise good health. EVIDENCE: A sample of service user’s care plans were examined and it was evidenced that all aspects of service users’ physical and cognitive needs are being appropriately addressed. Service users expressed their satisfaction with the help provided by care staff, and felt that their care needs are being well met. The service users’ risk assessments were also sampled and it was noted that they were not comprehensive enough and this might have an impact on the care being provided. The registered person must ensure that service users’ risk The Manse DS0000067467.V293119.R01.S.doc Version 5.1 Page 11 assessments give details to what action is required to minimise identified risks and hazards and are kept up to date. The registered manager was able to demonstrate, through individualised healthcare records, that service users are in regular contact with General Practitioners and other health care specialists as required. The home also keeps records of all the service users healthcare appointments, in addition to individual daily progress notes. In general, medication records, including medicines received, administered and returned were all being appropriately maintained. The registered person has met all the requirements made at the last inspection with regards to medication. Observation of the staff team interacting with the service users showed that the carers were mindful how they addressed service users, and they were seen to be polite and friendly. Service users are always treated with respect and dignity in accordance with the homes statement of purpose. The Manse DS0000067467.V293119.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. Service users are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Service users are able to exercise choice and control over their lives. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Service users are evidenced as being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and spiritual needs. The home is very well situated for local shops and public transport - which enables participation and integration into the local community. The manager stated that two service users go to church on a regular basis and that every last Sunday of each month the priest come to the home. The Manse DS0000067467.V293119.R01.S.doc Version 5.1 Page 13 Service users are encouraged to maintain contact with friends and relatives and to develop links with the local community. Service users are able to receive visitors in private and are able to choose whom they want to see or not to see. The service users’ comments and observation confirmed that the home is run in a manner that promotes choice and independence. Service users can bring in their own possessions and furniture if they wish and this was observed in service users’ rooms, which had been individualised. 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. The menus offer a choice of meals, and when the published menu options are not desired on the day, alternatives are offered. It was positively noted that consideration is also given to service users from ethnic minority groups as far as the menu is concerned. The Manse DS0000067467.V293119.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home has policies and procedures in place to deal with concerns and complaints however it needs amending to include the Commission’s name, address and telephone number. Service users are protected from abuse and are living in a safe environment as the home has appropriate adult protection policies and procedures in place. EVIDENCE: The home has a complaints procedure, which is good however it must be amended to include the Commission’s name, address and telephone number. It is also recommended that the home’s complaints procedure is made available in an appropriate language/format and is given and/or explained to each service user. The manager stated that service users are registered on the electoral roll and would be supported to vote if they wished to. The home has in place procedures for responding to suspicion or evidence of abuse, including whistle blowing, and passing on concerns to the Commission For Social Care Inspection. The London Borough of Croydon’s adult protection procedures were available in the office on request. There have not been any adult protection concerns raised. The Manse DS0000067467.V293119.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally hygienic, clean, homely and comfortable however some safety issues still need to be addressed as these potentially place service users and staff at risk. EVIDENCE: The home is suitable for its stated purpose. Furnishings and fittings were of good quality and the home was decorated to a reasonable standard. The garden is well maintained. The home is however not complying with fire regulations (see standard 42). This potentially places service users and staff at risk. Some of the bedrooms were checked. They were decorated to a good standard. The rooms contained a variety of personal furniture and fittings that reflected the individual’s personality. During the inspection it was noted that the windows on the second and third floor were opening wide and there were The Manse DS0000067467.V293119.R01.S.doc Version 5.1 Page 16 no restrictors on them. The manager gave reassurance that she would contact the registered provider regarding this issue and would ensure that the windows have restrictors on them as soon as possible. In the meantime the manager was advised to carry out a risk assessment. The manager is required to ensure that all windows have restrictors within twenty-eight days from the day of this inspection. It was also noted that the en-suite in room 5 on the first floor needed redecorating. The home is clean, hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. The Manse DS0000067467.V293119.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Generally staff are recruited appropriately to meet the health and social needs of the service users. However staff training needs to be addressed as this could have an impact on the standards of care being provided. EVIDENCE: Copies of the off duty rotas were seen. The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs. A cook and an assistant are always on duty to prepare meals. Staffing numbers and skill mix of staff are appropriate to the assessed needs of the service users, the size, layout and purpose of the home. Since the last inspection most of the member of staff have achieved a National Vocational Qualification in care level 2. The home continues to meet this standard, which the service providers, manager and her staff team are commended. Recruitment procedures seemed appropriate. Three 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.V293119.R01.S.doc Version 5.1 Page 18 The manager was able to produce documentary evidence of staff attendance of a variety of different training courses that were relevant to the work staff were expected to perform, including moving and transferring techniques, health and safety, and NVQ’s in care. However the manager must ensure that all staff are up to date with their training. The Manse DS0000067467.V293119.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36 and 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally managed well however the health, safety and welfare of service users and staff are not being promoted/protected and this potentially places them at risk. EVIDENCE: Throughout the course of the inspection the manager demonstrated a good competent management skills and appears to have created a skilled, positive and enthusiastic workforce. She has many years experience of working with this client group and displayed an insight into the relevant issues. She also undertakes regular training to keep herself up to date. The Manse DS0000067467.V293119.R01.S.doc Version 5.1 Page 20 The home has a good quality monitoring system. This ensures the home is run in a way that is in the best interests of the service users. It was previously required that the registered provider must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. From staff supervision records it seems that all staff are now having at least six sessions per year. A number of health and safety issues arose during this inspection and they are as follows: -A number of fire doors were wedged open. The registered manager must ensure that doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. -A number of fire doors, which have a notice stating, “ Keep lock shut” were unlocked and some were left open. The registered manager must ensure that fire doors are kept lock shut where indicated. -The magnetic catch in Room 20 was broken and was stopping the door from closing. The registered person must ensure that the magnetic catch is replaced. Failure to comply with the aforementioned requirements represent serious breaches of the Regulations and urgent action must be taken by the registered person to address these to avoid the Commission taking further action to enforce compliance. Certificates relating to health and safety were up to date servicing certificates. These included electrical wiring and installation, gas safety, fire safety and hoist maintenance. The Manse DS0000067467.V293119.R01.S.doc Version 5.1 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 2 3 3 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 2 17 3 18 3 2 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 2 The Manse DS0000067467.V293119.R01.S.doc Version 5.1 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 OP1 Regulation 4 and 5 Requirement The registered manager must amend the statement of purpose and service users guide to reflect the change in provider’s details and update any relevant information in both documents. The registered person must ensure that service users’ risk assessments give details to what action is required to minimise identified risks and hazards and are kept up to date. The home’s complaints procedure must be amended to include the Commission’s name, address and telephone number. The registered manager is required to ensure that all windows have restrictors fitted to stop them from opening wide. The en-suite in room 5 on the first floor must be redecorated. The registered manager must ensure that all staff are up to DS0000067467.V293119.R01.S.doc Timescale for action 31/07/06 2 OP7 15(1) 31/07/06 3 OP16 22(7) 31/07/06 4 OP25 13(4) 06/06/06 5 6 OP25 OP30 23(2)(b)( d) 12(1)(a) (b) 31/07/06 30/09/06 The Manse Version 5.1 Page 23 date with their training. 7 OP38 12(1)(a) 13(4) The registered manager must ensure that doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. The registered manager must ensure that fire doors are kept lock shut where indicated. The registered person must ensure that the magnetic catch on the door in Room 20 is replaced. 09/05/06 8 OP38 12(1)(a) 13(4) 12(1)(a) 13(4) 09/05/06 9 OP38 16/05/06 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 Refer to Standard OP1 Good Practice Recommendations It is recommended that the service user’s guide is made available in a language and/or format suitable for intended service users. It is also recommended that the home’s complaints procedure is made available an appropriate language/format and is given and/or explained to each service user. 2 OP16 The Manse DS0000067467.V293119.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 The Manse DS0000067467.V293119.R01.S.doc Version 5.1 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!