Care Home: Manormead Nursing Home

Similar services:

• The Shelley
• Springfield House
• Sutton Lodge Nursing Home
• St Helier`s Residential Hotel
• St Joseph`s
• Ridgemount
• Wingham Court
• Old Hastings House

What the care home does well The home has included service users in fire and evacuation training procedures. Service users told us they thoroughly enjoyed this and felt more empowered and more secure knowing what to do and expect from staff shoud the need arise. The manager has moved all people needing help with mobility to the ground floor, and move the more able bodied people upstairs. They have fitted a special bolt on all exterior doors, which require the glass bolt to be broken before the doors can be opened. We were told this is a safety feature of the home that has been advised by the fire department. The home has completed the "Essential steps to safe clean care", and achieved a score of 80% The home carries out a yearly Quality Assurance survey and analysis and changes are made to the running of the home based on the results of the surveys. Prospective service users and their relatives have the information needed to choose a home, which will meet their needs and service users are being assessed to ensure the home is capable to meet the needs of the service users prior to being admitted into the home. Practices in the home reflect service users` needs involving five strands of diversity: gender, age, religion or belief and disability. The home has a good and clear care plan in place for service users and this includes appropriate risks assessments. Which forms the basis for care based on the agreed care needs of the service users and demonstrated that trained staff met service users` health and personal care needs. The home`s medication policy on receiving, storing and administering of medication was in place and being adhered to thereby ensuring the safety and protection of the service users. Care workers treated service users with respect and maintain their dignity and privacy when delivering personal care. What has improved since the last inspection? The building works are now completed. There are new carpets throughout the communal areas of the home. There is a new Chapel with loop system to aid people with a hearing deficit. Changes to service times in the Chapel as some service users said they felt rushed. Evensong times and Complin times have also been altered following consultation with the Chapel Committee and the service users. The seating in the Chapel is not fixed and this allows for easy use by wheelchair using service users. A second dining room has been created to ensure service users dine in comfort. What the care home could do better: Fulfil the action plan for "Essential steps to safe, clean care" to ensure 100% rating. Start Equality and Diversity and Mental Capacity Act 2005 training for staff. CARE HOMES FOR OLDER PEOPLE Manormead Nursing Home Manormead Nursing Home Tilford Road Hindhead Surrey GU26 6RA Lead Inspector Mavis Clahar Unannounced Inspection 12th May 2008 09:05 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 Manormead Nursing Home DS0000035757.V363700.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. Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manormead Nursing Home Address Manormead Nursing Home Tilford Road Hindhead Surrey GU26 6RA 01428 602502 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) manormeadmanager@jtemail.co.uk www.c-of-e.anglican.co.uk http/www.c-ofe.anglican.co.uk The Church of England Pensions Board Mrs Diana Hearn Care Home 36 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (0), Old age, of places not falling within any other category (0) Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP and Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is 36. 10th October 2006 2. Date of last inspection Brief Description of the Service: Manormead is owned and operated by the Church of England pensions board, which is a charitable organisation. The board offers a variety of services throughout the country to retired clergy, licensed church workers and their spouses and widows (widowers). Manormead has been established for many years and nursing care is provided in the main building. The majority of accommodation is provided in single rooms, which have en-suite facilities. There are four double/shared rooms. There is a well-maintained garden and a conservatory that is used regularly by service users within the nursing home. The home caters for 36 older people over the age of 65 years. Accommodation is arranged over two floors and there are two lifts. Car parking is available at the front and rear of the building. Fees at this home are £602 per week. There is an additional cost for hairdressing, chiropody, personal telephone rental, transport and personal shopping. Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection, (CSCI) was undertaken by Mrs Mavis Clahar on the 12th May 2008 and lasted for nine hours; commencing at 09:05 hours and concluding at 18:05 hours. The CSCI Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This initially helps us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document was received by CSCI and is referred to throughout the report. The new manager of the home assisted CSCI (us) on this site visit. The majority of the service users spoken to were able to express their thoughts and feelings about the care they receive. The information contained in this report was gathered mainly from observation by the inspector, speaking with a number of service users, and with care staff and from information contained within the AQAA. Further information was gathered from records kept at the home. As part of this inspection we used our thematic probe based on “Safeguarding Adults”, as part of the methodology of IBL and the manager, three members of staff and two service users were asked and they agreed to participate. Their responses are included under Complaints and Protection and Staffing outcomes for service users. The first part of the inspection was spent discussing and agreeing the inspection process with the manager followed by a tour of the home, which included time spent in discussion with service users, care workers and the Head Chef. The manager and staff are aware of the Laws regarding equality and diversity and Equal opportunities and this was reflected in the staff mix. All service users in this home are Caucasian. All records sampled were up to date with care plans being signed by the service users or by relatives. One recommendation of good practice was Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 6 issued on this visit Please see Staffing outcomes for full disclosure. The final part of the inspection was spent giving feedback to the manager about the findings of this visit. The inspector would like to thank all the service users and care staff that made the visit so productive and pleasant on the day What the service does well: The home has included service users in fire and evacuation training procedures. Service users told us they thoroughly enjoyed this and felt more empowered and more secure knowing what to do and expect from staff shoud the need arise. The manager has moved all people needing help with mobility to the ground floor, and move the more able bodied people upstairs. They have fitted a special bolt on all exterior doors, which require the glass bolt to be broken before the doors can be opened. We were told this is a safety feature of the home that has been advised by the fire department. The home has completed the “Essential steps to safe clean care”, and achieved a score of 80 The home carries out a yearly Quality Assurance survey and analysis and changes are made to the running of the home based on the results of the surveys. Prospective service users and their relatives have the information needed to choose a home, which will meet their needs and service users are being assessed to ensure the home is capable to meet the needs of the service users prior to being admitted into the home. Practices in the home reflect service users’ needs involving five strands of diversity: gender, age, religion or belief and disability. The home has a good and clear care plan in place for service users and this includes appropriate risks assessments. Which forms the basis for care based on the agreed care needs of the service users and demonstrated that trained staff met service users’ health and personal care needs. The home’s medication policy on receiving, storing and administering of medication was in place and being adhered to thereby ensuring the safety and Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 7 protection of the service users. Care workers treated service users with respect and maintain their dignity and privacy when delivering personal care. 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. Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 8 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 Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 9 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 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Prospective service users and their relatives have the information needed to choose a home, which will meet their needs and service users are being assessed to ensure the home is capable to meet the needs of the service users prior to being admitted into the home. EVIDENCE: Review of service users documents and identified policies demonstrated the home has a policy and procedure for the admission of service users. Within the admission policy all service users must have an assessment prior to being admitted into the home. The Registered Manager, and in her absence, the matron who is trained in the principles of assessment of service users’ needs based on what the care the home says it will provide carries out pre admission assessments of service users prior to them being admitted into the home. In Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 10 instances where the proposed service user is living far away, a registered manager nearest to the residence of the proposed service user within the group will carry out the assessment. The home relies on the professional knowledge of other members of the primary health care team such as the GP the district nurse and any other group pf professionals providing care to the service user, who may have important information to assist the home in making a decision about the suitability of the home to meet the needs of the service user. The Annual Quality Assurance Assessment (AQAA) informs us that they only admit a resident following a full pre admission assessment ensuring that all personal, psychological, emotional and nursing needs can be met and where possible the potential resident or their relative have visited the home. Review of a random sample of service user’s files including one recently admitted service user, demonstrated that pre admission assessments are being carried out and relatives were being involved in the assessment process. We observed residents are provided with a contract, which clearly identifies information about fees and any additional charges. In discussion with service users they supported this observation, and contracts for the service users tracked on this visit were available for review. Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 11 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 10 People who use the service experience excellent quality outcomes in this area. This judgement has been using a range of evidence including a visit to this service. Practices in the home reflect service users’ needs involving five strands of diversity: gender, age, religion or belief and disability. The home has a good and clear care plan in place for service users and this includes appropriate risks assessments. Which forms the basis for care based on the agreed care needs of the service users and demonstrated that trained staff met service users’ health and personal care needs. The home’s medication policy on receiving, storing and administering of medication was in place and being adhered to thereby ensuring the safety and protection of the service users. Care workers treated service users with respect and maintain their dignity and privacy when delivering personal care. EVIDENCE: Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 12 The randomly selected care plans were clear and easy to read, identifying potential and actual risks to service users and detailing how these risks would be managed. The daily work sheet along with discussion with service users and care workers demonstrated that service users care needs are fully met. The service user or relative signed the care plans to indicate their involvement in deciding what care they received. It was evidenced that care staff undertaking the development and monthly review of the care plans also signed and dated them. In discussions with service users on the day of the visit they confirmed they were involved in the planning of their daily care. The AQAA Informs us that “comprehensive individualised care plans based on the Roper, Logan and Tierney Activities of Daily living model are developed for all residents, involving residents and where appropriate their family or friends. Regular audits and reviews are undertaken as a minimum monthly”. We observed the home uses recognised tools such as Waterlow score and Malnutrition Universal Screening Tool (MUST) during the care planning process to support decisions made. Information contained in the home’s Annual Quality Assurance Assessment (AQAA) states “We have access to and consult with specialist practitioners such as dieticians, speech and language therapist, dentists, opticians, audiologists, podiatrist, physiotherapist and tissue viability nurse when required”. This service enables service users to benefit from the involvement of specialist health professionals who supports the home in meeting the needs of the service users. All service users are registered with a local General Practitioner (GP) of their choice and visits are recorded, with access to specialist healthcare professionals through their GP practice as required such as sight and hearing tests which are carried out on a regular basis; and these visits are also recorded in the service user’s folder. Service users are offered access to chiropody service and weekly hairdressing facilities are available at a cost to the service users. The home employs their own physiotherapist and there is a well-equipped gymnasium for the use of the service users. In discussion with the registered nurse and care worker they were extremely proud of the high standard of care they provided to all service users in the home. We were told on the day of the visit that some service users at present are risked assess as capable to self medicate. The home had a policy on selfmedication and locked storage facilities are made available to service users who wish to self medicate. CSCI have received a number of Regulation 37 regarding medication and we were told Qualified staff have all received training in the receipt, recording, storage handling and administration and disposal of medicines and refresher courses have been planned to reinforce this training. All medicines are administered from a lockable drugs trolley. The home keeps a controlled drug register and record Medication fridge temperature daily. This was evidenced as correct during a tour of the home. Care staff identified as capable to administer medication are requested to Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 13 leave a sample of their signature, which is dated in the medication trolley. All service users have a recent photograph included in their personal folder and medication record, to reduce the risk of mistakes happening during medication administration. The AQAA informs us “the GP or Community Matron formally reviews all medication on a six monthly basis”. We observed that care workers wore name badges to enable visitors and service users with memory impairment to be sure of whom they are speaking with; and we also observed Service users being treated in a friendly but respectful manner by care workers. In discussion with service users who were able to understand the questions, they told us that they are treated with respect and dignity, and that they are able to make their own choice. One service user told us “I am very happy here. Everything is so nice. I have my own room; I can have as much privacy as I want”. Another service user said “We have good staff here; they treat me well. I have help to choose my own clothing every day”. All service users in this home are Caucasian, so the issue of race does not apply. However, the other five strands of equality and diversity were observed as being upheld. Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 14 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 15 People who use the service experience excellent quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Service users are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The home has sought the views of the service users and considered their varied interests when planning the routines of daily living and arranging activities both in the home and community. Routines are very flexible and service users can make choices in major areas of their lives. Service users lifestyles matched their needs and preferences and where possible they are able to maintain contact with family, friends and the local community. Service users are able to make choices in accordance with their abilities and were provided with a balanced diet in mostly pleasant surroundings and in an unhurried way. EVIDENCE: Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 15 The AQAA informs us that the routine of the home is greatly influenced by the services held in Chapel and the Christian Calendar. This home is a charitable home owned and operated by the Church of England (C/E) pensions board, catering for retired C/E Priests and their spouse. The home employs a full time activity-co-ordinator who provides a range of activities based on the individual service user’s assessed and agreed needs, including their preferences, cultural beliefs and customs. We were told that wherever possible relatives are encouraged to participate in the planning and carrying out of service users’ activities. The AQAA states, “the friends of Manormead also engage the service users in activities which develop social activities which will also aid in the exchange of ideas and best practice in the social activity function”. We were told the home has close links with the Friends of Manormead, who holds coffee mornings and bring and buy sales at the home. In discussion with the activities co-ordinator we were told, “we try to create and maintain a stimulating lifestyle for our service users to minimised the risk of a decline in their mental and physical health, through boredom, depression and lack of exercise, hobbies and games.” The home provides a full programme of activities based on the needs of the service users to include poetry reading, listening to classical music, service users participation e.g. some service users will give interesting talks on their past experiences. We saw proof of this contained within the May 2008 Manormead News Letter. We were told the activities co-ordinator visits service users on a weekly basis to gather information on what activities they would like for the next week and also to invite them to participate in the activities. Not all service users participate in activities, but this is ok we were told by the activities coordinator as service users have choice and autonomy to make their own decisions. We observed the activities record kept for each service user by the activities co-ordinator. On the day of the visit, at seventeen hundred hours the majority of service users were engaged in a Church service and we were told this is a daily occurrence. We were told many Service users have their own computers and the home provides a computer for all service users who wish to use it. We observed the activities programme displayed in the reception area of the home, in all the lounges used by the service users and in the dinning areas. The home does not have their own transport, but they have access to Care Cars and Hop-a-Bus which transport service users to places of interest and for service users personal shopping. The home has been successful in employing their own C/E Vicar, and services are held weekly services at the home, except during the months with five weeks when no service is held on the on Sundays. We were told by service users that they are able to have their friends and relatives visit any time it is convenient for them to visit. There is a private room set aside for service users guest to stay overnight should the needs Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 16 arise. A minimal charge is made for this. The guest for a minimal fee can also order meals. Service users spoken to said they had choice in their clothing and sometimes they receive help from their key worker. On the day of inspection all service users were dressed appropriately for the weather. The AQAA states, “The catering manager meets with service users on a monthly basis” where their opinions on the menu, meal and mealtimes are sought. The feedback from these meetings then influences any changes to the menu and mealtimes. We were told this ensures the catering department include service users’ input and suggestions on catering within the home and in development of the seasonal menu. In discussion with the Chef, it was evident he had a good working knowledge of the dietary needs of the service users, their likes and dislikes and was aware of all special diets for service users on the day of the inspection. We were told Service users are encouraged to choose their meal from the printed menu a day in advance, but they can change their mind on the day and a suitable replacement would be provided. On the day of the visit we observed the lunchtime meal and this consisted of a three-course meal with a choice of two hot main dishes. We observed a variety of fruit juices and water was served with lunch and service users had a choice on which beverage they wanted. We observed lunch was served to those service users who needed help with feeding first, so that staff were able to spend quality time helping the service user with their meal. We observed the home have created two very attractive and welcoming dinning rooms; the tables being dressed with freshly laundered and colour coordinated table linen condiments and vases of flowers, and daily menus which includes alternative choices to the main courses are displayed for the use of our service users. We observed jugs of water available on each table. The inspector did not sample the lunch, but service users said the food was very good, tasty and the right amount. The inspector observed the presentation of the food was done in a way to stimulate appetite. The Chef told us that some service users had supplements as ordered by their GP or dietician, to maintain body weight or increase appetite. Lunch, which was served in the dinning room unless a service user requested to have their meals in their bedrooms. We observed care workers interacting in a friendly but dignified manner with service users during the lunch time, sitting down beside service users and speaking to them whilst helping them with their lunches. Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 17 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 18 People who use the service experience excellent quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The home has a satisfactory complaints policy and procedure and training in place that evidenced that service users and relatives concerns are listened to and acted upon. Robust Safeguarding adults’ policies are in place to protect the service users from abuse. EVIDENCE: The home made one Adult Safeguarding notification to the local Safeguarding Team and this is currently being investigated on the day of the inspection. The manager has kept us informed of occurrences in the home by sending Regulation 37 notifications in which suitable actions are documented as taken. The AQAA stated “the home received four complaints in the last year all of which were dealt with within the home’s time frame for dealing with complaints, and none was upheld”. This was verified on the day of the visit by reviewing their complaints record, which demonstrated all complaints made, and the actions taken in response to them were fully recorded. We were told that a review of the number and nature of complaints made is used as part of the quality assurance procedures in use at the home. The home learns from Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 18 complaints in order to improve its service. They pay attention to any particular themes within complaints that refer to dignity, respect, autonomy and equality. The Manager told us that the management team are in touch with service users on a daily basis and issues raised are dealt with immediately; this reduces the incidents of formal complaints. Service users spoken to said they know how to complain and will do so if they are not happy. Their complaint is always dealt with immediately and they were satisfied with the outcomes. It was observed that the home’s guest information pack situated in reception contained a complaints procedure and policy; whistle blowing policy and the homes’ statement of purpose. It was noted that the home received a number of compliments from relatives of service users commending the staff on their kindness and understanding and for the high quality of work they perform. A copy of the most recent CSCI report is made available for visitors to the home in reception. In discussion with care workers, it was apparent they are aware of the homes’ policy and procedure on Safeguarding Adults and felt secure in the knowledge that if they had to use the whistle blowing procedure the manager and the Owners of the home would support them. During discussion with care workers it became apparent they had some knowledge on Equality and Diversity issues relating to the service users they were responsible for. A random sample of care workers training record demonstrated that care workers are being trained to undertake the duties of meeting the service users assessed needs, thereby protecting them from abuse. Instances where restraints (cot sides) were in use the care plans and risk assessments clearly documented the rationale for the use of restraints and the service user or relative signed the care plans to demonstrated their involvement in the decision making. We were told Service users are asked to wear a pendant alarm if walking alone in the grounds or if they are going to be alone in the Chapel. In discussion with service users we were told that they fully accept the reason for this request, and they also understand the request not to travel alone in the lifts. Risks assessments for both requests were observed signed by service users in their personal files. During this inspection we used our Thematic Probe on Safeguarding Adults as part of the inspection methodology. We interviewed the manager, three members of staff and two service users. We were told all staff has had training on Safeguarding Adults and the homes record on staff training supported this. All staff interviewed were knowledgeable on safeguarding issues including whistle blowing, and the actions to be taken if a safeguarding issue is suspected or arisen. Both the manager and trained staff were conversant with the completion of the Regulation 37 form and discussed their Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 19 responsibility to notify the safeguarding team at the local county council offices. The manager ensures the care staffs have access to all policies and procedures, by placing them in the staff sitting room and getting staff to sign when they have read and understood them Both service users interviewed told us they were each given a copy of the complaints procedure, which they keep in their bedroom. They understood how to complain, but so far has not had to use this facility. Usually they speak with the manager or matron whom they see every day. They also told us that the home took great care in protecting them, for instance we are asked to wear the pendant whenever we are going out in the grounds on our own or to the Chapel. We are also asked not to use the lifts on our own and that is just good sense. We appreciate these little thoughtfulness as it shows they care about our safety. Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 20 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 26 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The provider and manager have ensured that the physical environment of the home provides for the individual requirements of the people who live there and use the service. The living environment is appropriate for the particular lifestyles and needs of the service users and is homely, clean, safe and comfortable, well maintained and reflects the individuality of the people using the service. EVIDENCE: The building work at the home is now completed and has resulted in a vast improvement to the home. There is now a new bigger, airy and full of light Chapel with loop system installed to help those service users with a hearing Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 21 problem. The seating in the Chapel is not fixed and this allows for wheelchair users to use the Chapel, gaining access through the wide double doors. There is also a much-enlarged library and strategic seating for the use of the service users is placed along the wide corridor leading from the home to the Chapel and library. The manager told us that the management and staff encourage service users to see the home as their own home. The AQAA states “The service users are involved in the running of the home which is centred on the Christian ethos that is the foundation stone of the service users’ lives”. It presents as a comfortable, attractive home, which has specialist adaptations needed to meet the service users needs. The home employs a full time maintenance person who ensures the home, and facilities for service users are kept in excellent condition with records of service history available for inspection. The home employs a full time gardener who ensures the attractive gardens, is well maintained and there is good access to the gardens from various parts of the home. The attractive gardens have various sheltered seating placed at strategic points to enable service users to enjoy the garden and the view of the beautiful building. On the day of inspection we observed many service users sitting in the garden reading or just relaxing. It was noted they all wore the pendant, which is linked to the consul in reception to enable them to raise an alarm if they were in any trouble. We were told that the range of the pendant is very good as the home has aerials situated all around the outside walls of the building. We observed that all bedrooms had en-suite facilities with liquid soap and paper towels available to reduce the possibility of cross infection. Service users were able to personalise their bedrooms with small items of furniture, paintings on the wall and many family photographs. All bedrooms visited had a personal telephone in place and the manager told us all bedrooms have a telephone installed. We observed bathrooms have assisted baths installed and showers were available for the use of the service users. The home has its own hairdressing saloon, which is used twice weekly, a well-equipped gym, which is used by the service users under the direction of the resident physiotherapy. New carpets have been fitted to all communal areas of the home, and we observed new car parking facilities for disabled people situated to the front of the home. There is also new low-level lighting along the paths to ensure safety of people with sight impediment. It is apparent that the health and safety of service users had a great influence on the refurbishment of the home. Generally, the home presents as clean, safe, pleasant, hygienic and tidy and free from offensive odours. Random review of care workers training record demonstrated they have had training in infection control and this was evident Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 22 in the storage of waste. On display in the home is the Regulatory Reform (Fire Safety) Order 2005 stating the home has met their requirements. Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 23 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 30 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The home has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the home recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of the service users. The rota demonstrated consistently enough staff available to meet the needs of the service users in the home, with more staff available at peak periods of care giving. The staff structure is based around delivering outcomes for service users and is not led by staff requirements. EVIDENCE: The staff rota demonstrated the number and grade of staff on duty to provide care and attention to service users for any twenty-four period was adequate to meet the assessed care needs of the service users. Over 66 of care workers have attained the National Vocational Qualification (NVQ) Level 2 and above qualification. Review of care workers files Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 24 demonstrated that care workers had regular and up to date training to enable them to fulfil their roles. A random review of care workers files found that the home complied with the regulation regarding employment of staff to work in care homes. Records contained evidence that care workers attended all training offered. Recruitment to the home is through a process of equal opportunity, and in accordance with the code of conduct and practice set by the General Social Care Council (GSCC). All care workers have Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks and two written references prior to commencing employment, and they are in receipt of terms and conditions of employment as evidenced in their randomly selected files. There was evidence in the care workers files that they are supervised on a regular basis. All newly appointed care workers undertake an induction programme, and this was supported during discussions with a new member of staff. The home ensures that staff undertakes the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the care workers and by checking care workers’ training files. In discussion with care workers some were able to give examples of how the home applied equality and diversity to the different needs and wishes of the service users in their care, and also within the diverse staff group. As part of this inspection we used our thematic probe on safeguarding adults as part of the methodology, and care staff were interviewed on their safeguarding adults training. All staff interviewed told us they had received training based on the Surrey Multi-agency policy, and they were knowledgeable about how to recognise and report acts of suspicion of abuse. Staff files reviewed confirmed up to date training records. Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 25 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 38 People who use the service experience excellent quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The acting manager has the experience to run the home and works to continuously improve services and provide an increased quality of life for the service users. There is a strong ethos of being transparent and open in all areas of running the home. The views of service users and their relatives are actively sought in the running of the home and The service provides training on health and safety issues for all staff and service users are involved in the running of the home. Service users financial interests are safeguarded. EVIDENCE: Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 26 The AQQA contains excellent information that is fully supported by appropriate evidence. It includes a high level of understanding about the importance of equality and diversity and a wide range of evidence showing how they have listened to service users. The home demonstrates a high level of selfawareness and recognises the areas that it still needs to improve, and has clearly detailed the innovative ways in which they are planning to do this. The home fully recognises the importance of the AQQA and has used the content to inform its own quality assurance. The data section of the AQQA is accurately and fully completed and supports evidence in the self-assessment section. There have been substantial management changes since the last inspection of the home, including a new home manager and matron for the home. The manager is now registered with CSCI as the registered manager of the home. The manager has demonstrated that she has kept herself updated on issues relating to care of service users and staff in her charge. She is a Registered General Nurse with BSc (Hons.) Clinical Practice, and holds the Registered Managers Award (NVQ L4) qualification and has many years experience of nursing and management. In discussion with the manager it was evident she was knowledgeable about the care needs of the service users and the training needs of the care workers to meet the identified care needs of the service users. There are clear lines of accountability within the home; each member of staff spoken to on the day of the inspection was clear about their role and responsibilities. The majority of the service users are able to be involved in the running of the home, and one service user is on the dietary discussion and planning team. Relatives are encouraged and enabled to be as involved in the running of the home as their time will allow them to be. One service user said, “The manager, matron and sisters in fact all the staff are very nice and they listen to what we have to say. We have regular meetings”. Minutes of the residents meetings are kept on file for review. We were informed that the home does not become involved with service users’ finance except for those service users who have asked for their spending money to be kept by the home and receipts are kept on file for all transactions undertaken. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day was properly maintained. Records indicated that fire drills, fire alarm, water temperature were regularly checked. Random sample of care workers’ training files demonstrated that up to date and relevant training were carried out by care workers to protect service users’ health, welfare and safety. In discussion with care workers it was evident that they had an understanding and implementation of appropriate procedures to Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 27 safeguard service users, and they spoke about their understanding of promoting safe working practices based on their health and safety training. Staff also told us that they had one to one supervision with the manager and this was collaborated during review of staff training records. The AQAA states “A Health and Safety Advisor visits the home twice yearly and is available for advice.” We were told that health and safety meetings are held weekly and formal checks and risk assessments are undertaken monthly or sooner if required to ensure that a safe environment is maintained and safe working practices are up held. Records of these meetings were made available to us. We were also told that a Fire officer and a Health and Safety Officer undertook recent inspections and that there were no requirements made from either visits. Quality Assurance is achieved through the monthly Regulation visits and through the yearly quality assurance survey. On the day of the visit, we observed many completed returned questionnaires. We were told the date for return is another week ahead. This information will then be collated and analysed and distributed to all involved in the survey. Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 28 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 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 29 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. 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 OP30 Good Practice Recommendations The registered person should arrange training for staff in Equality and Diversity and Mental Capacity Act 2005. Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Manormead Nursing Home DS0000035757.V363700.R01.S.doc Version 5.2 Page 31 - 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!