Inspection on 12/01/06 for David Gresham House

This inspection was carried out on 12th January 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

David Gresham House 03/10/06

David Gresham House 16/06/05

David Gresham House 01/09/04

David Gresham House 05/04/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE David Gresham House David Gresham House 226 Pollards Oak Road Hurst Green Oxted Surrey RH8 0JP Lead Inspector Sarah Radlett Unannounced Inspection 12th January 2006 09:15 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 David Gresham House DS0000013622.V262840.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. David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service David Gresham House Address David Gresham House 226 Pollards Oak Road Hurst Green Oxted Surrey RH8 0JP 01883 715948 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) Abbeyfield North Downs Society Limited (The) Mrs Pamela Ann Packham Care Home 28 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (3), Sensory Impairment over 65 years of age (3) David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The combined total of service users within categories PD(E), DE(E) and SI(E) shall not exceed six (6) 16th June 2005 Date of last inspection Brief Description of the Service: David Gresham House is a residential home for older people owned by the Abbeyfields North Downs Care Society Limited. The home is located in the village of Hurst Green, near Oxted. There is a small parade of shops adjacent to the home. There are outdoor areas for residents to use and there are raised flowerbeds in some areas. There is a parking area to the front of the building with additional parking on the road. The Home offers accommodation for twenty-eight residents, of which up to two places can be used for respite care. The home offers single bedroom accommodation with the majority of the rooms having en-suite facilities. There are two lounges, a conservatory, large dining room, art/therapy room, a hairdressing salon and treatment room for use by the district nurse. David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3½ hours and was the second inspection carried out by the Commission for Social Care Inspection for the year 2005-2006. Sarah Radlett carried out the inspection. The Registered Manager, Mrs P Packham, was present throughout the inspection. A partial tour of the premises took place and various written records were examined, including the homes Statement of Purpose, six care plans and service user assessments, staff recruitment files, staff training records, the complaints log, some of the medication administration records and a sample of policies and procedures. The inspector spoke to Service Users, and some of the staff on duty at the time of the inspection. The Inspector would like to thank the staff and Service Users for their time, assistance, and hospitality during the inspection. What the service does well: What has improved since the last inspection? Following the previous inspection all Service Users who self-administer their medication had appropriate and comprehensive risk assessments. All risks identified had a clearly documented action plan. David Gresham House DS0000013622.V262840.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. David Gresham House DS0000013622.V262840.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 David Gresham House DS0000013622.V262840.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, 4, 5 & 6 The information enabling Service Users to make an informed choice about where they live was available to all existing and prospective Service Users. Service Users were issued with an appropriate contract and received a copy of the homes terms and conditions. Service Users are usually admitted to the home for two months respite and have a full needs assessment prior to becoming a permanent Service User. EVIDENCE: All Service Users had been given a ‘residents pack’ which included the homes Statement of Purpose. This contained all the required information and Service Users were fully informed about the services the home could offer. Samples of Service Users contracts were seen, Service Users also received a copy of the homes terms and conditions. These two documents were clearly presented and had been signed by the Service Users. David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 9 Service Users are usually admitted for two months respite during which time they have a full needs assessment. Therefore a full assessment of Service Users needs is carried out prior to Service Users becoming permanent to ensure that the home can meet their needs. This admission policy is clearly documented in the homes Statement of Purpose. Samples of the Service Users assessments were seen and found to be comprehensive. Intermediate care was not provided at the home. David Gresham House DS0000013622.V262840.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 & 10 Comprehensive care plans were in place, they were well organised and clearly set out the Service Users health, personal and social needs; however one care plan was found to be incomplete. Risk assessments were comprehensive. The medication administration records were satisfactory. Care was provided in a dignified, respectful manner. EVIDENCE: Six care plans and Service User assessments were randomly selected for inspection. The care plans set out in detail the action that needed to be taken to meet the assessed needs. There was evidence of regular review and Service Users had signed the care plans and the reviews to evidence their involvement in their care. However the examination of these records found one Service Users care plan and assessment file had not been filled in. A requirement has been made. David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 11 Samples of risk assessments were inspected. comprehensive and up to date. They were found to be All Service Users were registered with a local GP. Service users had access to visits from a variety of other health care professional services including district nurse. The medication administration records were satisfactory. Service Users who self-administer their medication had appropriate risk assessments. Staff were observed to carry out their care duties in an appropriate manner and to respect the service users privacy and to treat them with dignity. Service Users spoken with were complimentary regarding the home. Comments from Service Users included ‘it’s a lovely home’ ‘I’m very happy here’ and ‘I cannot find fault with anything’. David Gresham House DS0000013622.V262840.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 & 14 The service users were enabled to maintain their independence as much as possible. Activity provision met the needs of the Service Users. Service Users were encouraged to make choices. EVIDENCE: The activity programme was available throughout the home. Service Users spoken to were happy with the activities provided and were able to participate or abstain according to their wishes. Comments from Service Users included ‘there is plenty to do’, ‘there is lots of company and entertainment’ and ‘we are very lucky to be so close to the shops’. Service users were encouraged to personalise their rooms, evidence of this was seen on the day of the inspection. Staff were observed to give the service users appropriate choice. David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The complaints procedure was available to all Service Users. All care staff had received protection of vulnerable adults training, the homes prevention of abuse policy requires updating. EVIDENCE: A copy of the homes complaints procedure was contained within the Statement of Purpose, which was distributed to all Service Users. No complaints had been received since the last inspection. The staff training records were examined and the care staff had received training in the protection of vulnerable adults. The homes prevention of abuse policy was examined and found to contain ambiguous information regarding the reporting and investigating of any allegations or suspicions. A requirement has been made that the policy is updated in line with the Surrey Multi-Agency Prevention of Abuse Policy, which states that any allegation should be referred to Social Services and must not be investigated by the home. David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home was suitable in layout for its purpose. The home was found to be accessible, safe and well maintained with a pleasant homely atmosphere. EVIDENCE: The inspector toured areas of the home. It was seen to be warm and bright with a very high standard of housekeeping. The garden area was well maintained and accessible to Service Users. The premises were well maintained and no offensive odours were present. David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 15 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 & 30 The staffing arrangements in place on the day of the inspection were sufficient to meet the needs of the Service Users. Service Users were protected by the homes recruitment procedures. Staff received appropriate supervision and training. EVIDENCE: The staff rota inspected demonstrated that the staffing numbers and skill mix were appropriate to meet the assessed needs of the Service Users living in the home. The home is committed to NVQ training, five staff members had currently completed level 2 and two had completed level 3, the home had two NVQ assessors and an ongoing NVQ training programme. Samples of staff files were examined at inspection and found to be clearly set out and contain all the required information. All new staff were supervised during their induction period. The staff training files were examined and all staff had undertaken regular training in mandatory topics including first aid, infection control, manual handling and fire. Some staff had also had training in understanding dementia David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 16 and visual awareness. An ongoing training plan was in place to ensure that all staff received this additional training. David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 17 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, 32, 35, 36, 37 & 38 The Registered Manager is competent and capable to manage the home. Systems were in place to safeguard the financial interests of Service Users. Staff received regular supervision. Policies and procedures were in place to ensure, as far as is reasonably practicable, the health, safety and welfare of service users and staff. EVIDENCE: The Registered Manager demonstrated good leadership qualities at inspection, all staff and Service Users were observed to respond to her in a positive manner and appeared very pleased to see her. All interactions observed between the manager, staff and service users evidenced an open, positive and inclusive atmosphere. David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 18 During the inspection, the Registered Manager presented a clear understanding of the home’s purpose and a grasp of the management challenges. There was clear evidence of team work between the Registered Manager and other staff. Procedures were in place to safeguard the financial interests of Service Users. No members of staff have any dealings with the finances of the Service Users. The Registered Manager stated that all the Service Users were able to manage their own finances. Service Users had lockable storage in their rooms and a safe was available in the office. Staff supervision records were inspected and staff received regular formal supervision. A sample of the records within the home were inspected and found to be accurately completed and up to date. Required health and safety training had taken place, including fire prevention. Required servicing certificates had been previously inspected and seen to be in order to ensure so far as is reasonably practicable, the health, safety and welfare of service users and staff. David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 19 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 3 3 3 3 3 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 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 3 3 David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 14(2)(b) 15 (2)(b)(i) 13 (6) Requirement The Registered Manager must ensure that the individual care plans for all service users are kept up to date and fully completed. The Registered Manager must ensure that the prevention of abuse policy is updated to include clear reporting guidelines and actions to be taken. Timescale for action 12/02/06 2 OP18 12/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 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 David Gresham House DS0000013622.V262840.R01.S.doc Version 5.1 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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