Inspection on 05/12/05 for Arbrook House

This inspection was carried out on 5th December 2005.

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

The inspector 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

Arbrook House 18/06/07

Arbrook House 31/05/06

Arbrook House 25/08/05

Arbrook House 26/10/04

Arbrook House 07/06/04

Arbrook House 25/05/04

Arbrook House 01/04/03

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Arbrook House 36 Copsem Lane Esher Surrey KT10 9HE Lead Inspector Denise Debieux Announced Inspection 5th December 2005 10:00 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 Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 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. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Arbrook House Address 36 Copsem Lane Esher Surrey KT10 9HE 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) 01372 468246/7 01372 470760 BUPA Care Homes Limited Ms Keena Sinclair Millar Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 44 Residents accommodated, 4 may also fall within the category TI(E) Terminally ill, Elderly 25th August 2005 Date of last inspection Brief Description of the Service: Arbrook house is situated close to Esher town centre and Claremont Landscaped gardens. The home is situated in its own landscaped grounds with its own lake. The home is registered for forty four older people and the accomodation is provided over two floors and can be accessed by lift. All rooms are for single occupancy and have en-suite facilities. The home has a large communal sitting room and a large dining room. There is a conservatory and separate smoking area for residents who wish to smoke. There is a patio area to the rear of the house overlooking the grounds and the lake. Parking is available at the front of the building. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Ms Keena Millar (Registered Manager) was present as the representative for the establishment. Prior to the inspection, survey forms were sent to the home and distributed to service users, with eleven being returned, to their relatives, with eighteen being returned and to GPs and health and social care professionals, with five being returned. The results of these surveys and comments made are used in this report. A tour of the buildings took place with eight service users and seven on-duty staff being spoken with during the tour. The menus, care plans, staff rota, recruitment information and suggestion book were all sampled. The inspector would like to thank the service users, manager and staff for their time, assistance and hospitality during this inspection and the service users, their relatives and health and social care professionals who participated in the surveys. What the service does well: What has improved since the last inspection? The ongoing maintenance and redecoration of the home and gardens provide the service users with homely and comfortable surroundings in which to live. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 6 Recent servicing and upgrade to the call bell system has reduced the amount of times the system breaks down. 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. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 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 Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 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): NONE EVIDENCE: Standard 3 was fully assessed and met at the last inspection and was not covered on this occasion. Standard 6 does not apply to this home. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The service users’ health and personal care needs are set out in an individual plan with documentary evidence of the health care needs being met. EVIDENCE: All relatives and health care professionals surveyed stated they were satisfied with the overall care provided at the home, with ten of the eleven service users saying that they felt well cared for and one answering ‘sometimes’. Three care plans were sampled during this inspection. They were all based on comprehensive needs assessments and included all areas of identified needs and appropriate risk assessments. The care plans sampled had been signed by the service user or their representative to signify their agreement with the contents. The carers document daily notes, which were seen to relate to the care plans. The trained nurses write on evaluation sheets. Some comments received from service users surveyed indicated that the care provided does not always correspond with the care plan they have agreed to. There were also comments referring to a lack of consistency and service users having to explain to carers what they require. At present the care plans are all kept in the nurses’ office on the ground floor and are written and maintained by the trained nurses. It has been recommended that the care plans are Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 10 stored in a place where they are more easily referred to and that the care assistants become more involved in writing and updating the care plans. The possibility of storing the care plans in the service users’ own rooms was discussed. There is a new Deputy Manager starting work on the 6th December, the manager plans to discuss options with him and implement a change to the storage system over the next couple of weeks. The manager also has plans to review the system of documentation to try to reduce the level of duplication, involve the service users and the care assistants more and hopefully free up time for all staff to be ‘on the floor’ working with the service users more. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Meals are well-balanced and varied with special dietary needs catered for. EVIDENCE: Of the eleven service users surveyed, five said that they liked the food, one said they did not and five answered ‘sometimes’. The food provided is an area that the home has been working hard to improve over the past few months. Changes have recently been made and a meeting was held, on the 11th November, with service users and their relatives to discuss the changes. It should be noted that the majority of the comment cards quoted above were received prior to the 11th November and it has been recommended that the manager carry out a further survey to assess the success of the recent changes. The menus for four weeks were sampled and seen to provide a varied diet with choices and alternatives available if wanted. The home has recently added a new ‘light menu’ alternative. During this inspection the lunchtime meal was taking place. The food was served hot and attractively presented. Eight service users spoken with all indicated they were enjoying their meal. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 12 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 The home has a simple, clear and accessible complaints procedure which includes timescales for the process. EVIDENCE: The home has a detailed complaints procedure in place. The procedure has been given to each service user, is posted in the lift and is also included in the Statement of Purpose and Service Users’ Guide. All service users surveyed commented that they knew who to speak to if they had a complaint. Two comments were received prior to the inspection that indicated that the outcome of complaints were not always fedback. In discussion with the manager it was felt that this could relate to some issues raised in the home’s ‘suggestion book’. At present there is a column that sets out action taken following the suggestion, (i.e. a request being made for a service call). The manager is now going to add an additional column so that the outcome of the issue can be added when resolved. In addition, suggestion forms have now been placed next to the visitors signing-in book in case people want their suggestions to be more private. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 13 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): 26 The location and layout of the home is suitable for it’s stated purpose and the home was clean, pleasant and hygienic on the day of the inspection. EVIDENCE: At the previous inspection a recommendation was made that a carpet be deep cleaned, this has now been done. The home was toured and the premises were seen to be well maintained with service users able to access all areas of the home and grounds. Service users spoken with expressed their satisfaction with the accommodation provided at the home and many of the individual bedrooms were seen to be individualised with the service users’ own personal items and mementos. On the day of inspection the home was found to be warm, clean and bright with a homely atmosphere. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 14 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 and 29 The staffing levels need to be reviewed to ensure that the needs of all service users are met at all times and action must be taken to improve the staff recruitment procedures to ensure that the service users’ safety is protected. The home has an NVQ staff training programme which is designed to ensure, as far as reasonably possible, that service users are in safe hands at all times. EVIDENCE: Of the eighteen relatives that returned comment cards, eight stated that they did not feel there were always sufficient numbers of staff on duty with additional comments made by service users and relatives that call bells were not always answered promptly and that they felt there was a shortage of staff. Staffing levels were looked at in some depth during this inspection. The Residential Forum system was used to check the staffing numbers for the amount of service users currently accommodated at the home and the rota reflected the required level apart from the hours between 7 and 8am and 8 and 10pm, which need to be increased. Following the previous inspection the call bell system has been serviced and upgraded, which has reduced the number of incidents of breakdown of the system. The manager has also carried out a study of the times taken to answer call bells, identified peak times of concern and has begun to put measures in place to deal with the problems. The main areas of concerns are mealtimes and directly after mealtimes. The home have now introduced two to three extra members of staff that start at 7.30am to assist with breakfasts and one extra member of staff that works until 10pm to help the night staff. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 15 At present there are a high number of service users that require different levels of supervision or assistance with meals and whilst the number of staff on duty exceeded the level indicated by the Residential Forum guidance, the amount of staff available to assist the service users at the lunchtime meal observed were insufficient. Two members of staff were observed trying to feed five service users between them at one point, although the manager immediately allocated extra staff when this situation was seen. As stated above, and as this is an area of concern that the manager is currently taking steps to improve, the requirement made at the previous inspection has been carried forward with a limited extended deadline. The manager expressed a strong commitment to National Vocational Qualification (NVQ) training for the staff and over 50 of the care assistants are qualified to NVQ level 2 in care or higher. Sixteen of the twenty-nine carers have already achieved NVQ level 2 qualifications, a further three are enrolled to start the training soon and three carers are scheduled to go on to study NVQ level 3. Two staff files were reviewed at this inspection and were found to contain much of the information required of the regulations, i.e.: proof of identity, Criminal Records Bureau certificates, two references and medical declarations. However, the files inspected did not include full employment histories, reasons for leaving previous jobs were not always verified and gaps in employment were not fully explained. Also discussed with the manager was the requirement of the home to have written confirmation that any agency workers have had all the checks carried out as detailed in The Care Homes Regulations 2001. Requirements and a recommendation have been made related to these issues. All service users spoken with confirmed that the staff treat them well and all interactions observed between the staff and service users during this inspection were seen to be caring and respectful. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 35 Service users’ financial interests are safeguarded by the policies and practices of the home. EVIDENCE: The inspector was advised that the home do not handle financial affairs for any service users. However, on occasions when service users want valuables stored securely for a short period of time, the home has a safe which can be used. Any items stored in this way are recorded in the service users’ files and service users or their relatives are provided with receipts. All service users surveyed and spoken with confirmed that they felt safe at the home. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 17 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 18 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 OP27 Regulation 18(1)(a) Requirement The registered person must review the staffing levels at the home and ensure that suitably qualified, competent and experienced persons are working at the home in such numbers to meet the needs of the service users accommodated at any one time. Timescale for action 19/01/06 (Timescale of 25.10.05 not met) 2 OP29.1-6 19(1)(a-c) The registered person must not Schedule employ a person to work at the 2 care home unless the person is fit to work at the care home and he/she has obtained, in respect of that person, the information and documents specified in paragraphs 1 to 9 of Schedule 2 of the Care Homes Regulations 2001, as amended by The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. 05/12/05 Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 19 3 OP29.1-6 4 OP29.1-6 19(1)(a-c) The registered person must Schedule obtain the following information: 2 • full employment history • explanation of any gaps in employment • verification of reason for leaving employment • two satisfactory, written references, including, where applicable, a reference relating to the last period of employment which involved working with vulnerable adults retrospectively for each member of staff employed by the company after The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 came into force on 26th July 2004. 19(4)(a-c) The registered person must not Schedule allow an agency worker to work 2 at the care home unless he/she has received written confirmation that the agency have obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001, as amended by The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. 05/01/06 05/12/05 Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 20 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 2 3 4 Refer to Standard OP7 OP7 OP15 OP27 Good Practice Recommendations It is recommended that the manager review the storage of the care plans to enable the care assistants and nurses to refer to them easily when working with the service users. It is recommended that the care assistants become more involved in compiling and updating the service user plans. It is recommended that the manager carry out a survey with the service users related to the recent changes in the menus and food provision. It is recommended that BUPA Care Homes Ltd review their employment application form to encompass the new requirements of Schedule 2 of the Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). E.G. request a full employment history instead of the past 10 years only; ask for reasons for leaving previous jobs; ask for gaps in employment to be explained; etc.. Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Arbrook House DS0000013300.V257629.R01.S.doc Version 5.0 Page 22 - 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. 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