Inspection on 16/06/05 for David Gresham House

This inspection was carried out on 16th June 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

David Gresham House 03/10/06

David Gresham House 12/01/06

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 226 Pollards Oak Road Hurst Green Oxted Surrey. RH8 0JP Lead Inspector Mrs M McHugh Announced Inspection 16 June 2005 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 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 H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service David Gresham House Address 226 Pollards Oak Road, Hurst Green, Oxted, Surrey. RH8 0JP 01883 715948 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Abbeyfield North Downs Society Ltd Mrs Pamela Packham CRH (PC) 28 Category(ies) of Old age, not falling within any other category registration, with number (OP) 28. of places Dementia - over 65 years of age (DE(E)) 3. Physical Disability - over 65 years of age (PD(E)) 3. Sensory Impairment - over 65 years of age (SI(E)) 3. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The combined total of service users within categories PD(E), DE(E), and SI(E) shall not exceed six (6). Date of last inspection 01 September 2004 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 offers accommodation for twenty Eight residents, of which up to two paces can be used for respite care. The home is located in the village of Hurst Green, near Oxsted. There is a small parade of shops adjacent to the home. The home offers single bedroom accommodation on the ground and first floors with the majority of the rooms having en-suite facilities. Therr are two lounges, a conservatory, large dining room, art/therapy room, a hairdressing salon and treatment room for the district nurse. The home has outdoor areas for residents to use and there are raised flower beds in some areas. There is a parking area to the front of the building with additional parking on the road. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out over seven hours. A tour of the premises was undertaken and staff and care records were sampled during the day. Staff were spoken with during the course of their duties and seventeen of the twenty-six residents were spoken to during the course of the day. Two visitors also talked with the inspectors and gave feedback about the service. The inspector received back comment cards from thirteen residents, three relatives/visitors and one from a GP. The inspector had the opportunity to receive feedback about the home from a visiting district nurse on the day. What the service does well: What has improved since the last inspection? Many areas of the home have been redecorated including the lounge. Carpets have been replaced in the lounge, area outside the kitchen and up the stairs. The chairman of the committee advised the inspector that the home plans to replace some of the windows that have had some sun damage in the coming year. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 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 H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 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 standard(s) 1, 2, 3, 4 and 5 Residents have access to information about the home to enable them to make an informed choice about the service. This includes information about the level of needs the home can cater for and any specialist equipment available. Contracts were in place for all residents. People are invited to visit the home prior to making a decision about admission to the home. EVIDENCE: The home’s statement of purpose and resident’s guide was available and contained information about the home, activities, meals, staff and more. The manager stated that the home was awaiting their new certificates from CSCI with the new Responsible Individual’s name on them and then the statement of purpose would be updated. Residents files sampled contained contracts between the home and the resident and/or the funding authority. These contracts included the room that the person was to occupy and information about any additional costs that are not covered in weekly fees. There was also a terms and conditions of residence in each file that was signed by the resident or their representative. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 9 All residents are assessed by the home and/or by the social care team prior to admission. The resident then has a comprehensive admission assessment completed which looks at physical, emotional, social, health and nutritional needs. These are reviewed as part of the care planning process each month. Any needs that are identified as requiring specialist equipment are provided through the home or the occupational therapist. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 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 standard(s) 7, 8, 9, 10 and 11 The resident’s health, personal and social needs were documented in the care plan and their health care needs were being met. The medication was administered in the correct manner and records were accurately completed. However, there were no risk assessments in place for residents who are responsible for their own medication. There were no issues identified around privacy or dignity. EVIDENCE: The care plans sampled were comprehensive and contained the individual risk assessments completed by staff. It was noted that some risk assessments stated that the resident was in a high risk category but no action plans were in place to reduce the chance of the identified risk occurring. All plans were reviewed on a monthly basis by staff and the review was a comprehensive look at the care being provided to the resident and any changes that had occurred during the month. The care plans are signed by the resident and staff. This was good practice and staff were commended. The daily notes were completed during each shift and these were informative about the individual’s care needs met during the day, what activities they participated in, meals taken and emotional needs assessed. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 11 Records of external professional’s visits were viewed and showed that the GP, optician and chiropodist make regular contact in the home. Residents stated that they could see the GP when they were unwell. The district nurse visited the home on the day and informed the inspector that they visit the home on request and that the home responds quickly when a resident requires input from the district nurse team. The lunchtime medication round was observed and this was carried out according to the Royal Pharmaceutical guidelines. No gaps were noted in record sheets and the relevant symbols were being used when medication was not administered. Staff need to be aware that any medication that is hand written onto the administration records should be signed by two members of staff to say that they have checked the information that is written in, is correct. A number of residents are responsible for their own medication and staff assist these residents with the ordering if required. All residents who selfadminister their own medication have signed a waiver form to say they will take full responsibility of their medication. However the home needs to carry out a risk assessment for each individual to ensure they are able to safely do so. A random count of controlled drugs was carried out and these tallied with the amounts in the register. No issues of privacy or dignity were brought to the inspector’s attention and staff were observed to be knocking on bedroom doors and calling residents by their preferred form of address. Of the thirteen comment cards received back from residents, one stated that their privacy is not respected and another said it was sometimes respected. (This could not be followed up at the inspection as both were anonymous.) Staff have attended training in dealing with bereavement and the home’s policy is clear about steps the home must take. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 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 standard(s) 12, 13, 14 and 15 Social activities and mealtimes were well managed and provided a choice, daily variation and social contact for residents. Residents had a right to make choices and exercised some control over all aspects of daily living. EVIDENCE: The activities programme was available around the home and in resident’s bedrooms. Residents advised the inspector that there was scrabble and bridge in the dining room after lunch and that there had been a prayer morning held in the conservatory/chapel in the morning. Residents stated that they had attended a number of special activities in the last few months including trips out. One resident stated that there was so much going on they didn’t have enough hours in the day to do all the activities. Two residents informed the inspector that they go out to a workshop twice a week for their needlework. Visitors were seen in the home throughout the day and many stated that they were welcomed into the home at any time and were always treated with respect and offered refreshments. Meals were served in the dining room or in resident’s bedrooms, depending on their preference. Residents were very complimentary about the food provided, David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 13 choices offered and the environment the meals were served in. Of the thirteen resident’s comment cards received back, three stated that the they sometimes liked the food, one stated that they did not like the food and on the day of the inspection the fourteen residents spoken with at lunchtime all stated that the food was nice and tasty. The lunchtime meal offered a choice of four main meals and dessert. The desserts are brought around on a sweet trolley and offered three choices residents even those on special diets. Staff were observed to remain in the dining room available to assist any resident and to serve the next course as required. The kitchen was clean and well stocked. The chef stated that they go around every morning to take down the orders for the day and that residents’ input is taking into consideration when planning the menus. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents and relatives are aware of how and who to complain to and were satisfied that the home would respond accordingly. Procedures were in place in respect of the protection of vulnerable adults and training and induction was available for staff. EVIDENCE: All residents and relatives spoken with stated that if they had cause to complain they were aware who they could complain to. They stated that staff react quickly if there is anything that is not satisfactory or up to standard and therefore have no reason to complain. Staff receive training in their induction and full abuse training that teaches them how to recognise signs of abuse and what to do if they witness or suspect that a resident is being abused. Residents spoken to stated that staff were caring, kind and polite at all times. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The home is safe, well maintained, provides comfortable communal areas and residents have bedrooms to suit their needs. The home has sufficient heating, ventilation, lighting and is clean and free from malodours EVIDENCE: All areas of the home were well maintained and there has been redecoration to a number of areas of the home including a full redecoration of the main lounge, carpets replaced in the lounge, outside the kitchen and the stairs. The chairperson of the home stated that they hope to replace some windows in the near future as these have had some sun damage. The home provides a number of communal areas including a large main lounge, a conservatory (also called the prayer room), dining room, upstairs lounge and art room. There are a number of outside areas residents have access to including a patio with raised flower beds for residents to tend to. All bedrooms are for single occupancy and many have en-suite facilities. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 16 Those bedrooms that were viewed on the day of the visit, were large in size, many exceeding the National Minimum Standard’s size requirements, and were decorated with residents’ furniture, photos, pictures and ornaments. Residents stated that the staff were helpful in decorating their bedrooms and hanging photos. Many residents stated they liked their bedrooms and that they were spacious. Specialist equipment in the form of handrails, safety rails in bathrooms, specialist baths, hoists, wheelchairs, zimmer frames and specialist pressure relieving equipment was found throughout the home. The hot water, lighting and ventilation in the home were seen to be satisfactory and the maintenance person carried out regular checks on all equipment. The home employs a dedicated housekeeping staff team and they discussed the training they had received and showed a good awareness of COSHH (Control of Substances Hazardous to Health) and infection control issues. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The staffing levels in the home are satisfactory to meet the needs of the current residents. The home’s recruitment practices protected the residents and staff were trained to do their jobs. EVIDENCE: The staffing levels in the home were seen to be satisfactory to meet the current residents needs. Most residents stated that staff were kind, patient and that they were not rushed at any time. One residents stated that staff always come promptly when called. Some staff were attending a training course on the day of the inspection and staff records showed that all staff have up to date mandatory training in place including fire, first aid, manual handling/back care, food hygiene, prevention of abuse, principles of care and infection control. Eight staff have a certificate in NVQ level 2, six staff are currently on the NVQ level 2 course, two staff have completed and five staff are undertaking the NVQ level 3 course and one is currently on the NVQ level 4 in care course. The staff files sampled contained the information that is required by legislation including proof of identification, written references, evidence of qualifications, employment history and Criminal Record Bureau (CRB) checks. Copies of the training programme, CRB record numbers and staff qualifications were provide to the inspector. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 18 David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 36, 37, 38 The home has good leadership, guidance & direction and the staff are aware of their responsibilities to ensure residents receive consistent quality of care. Residents benefit from the ethos and management approach in the home and their safety and welfare is promoted. EVIDENCE: Records of staff meetings, committee meetings and residents meetings were seen. Staff were observed to interact openly with the manager and be at ease in her presence. Residents responded well towards the manager and many were pleased to see her. The visitors spoken with stated that the home promotes good communication and that they are kept up to date with information about their loved ones. The manager stated that the home gave residents CSCI’s comment cards to complete instead of their own questionnaires as it was felt it would be too David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 20 much to ask them to complete both sets. Evidence of previous years questionnaires viewed. The home is a registered charity and depends on income and donations to supplement their income. The bursar informed the inspector that the home’s finances were in a satisfactory state. A copy of the home’s financial statements were seen and satisfactory. The home has a business plan in place and many of the objectives for the year were in hand. All records sampled were accurate and up to date. Supervision takes place and staff receive up to six sessions of supervision in a year. Fire testing, maintenance, health and safety checks records were up to date and well maintained. The home promotes the health, welfare and safety of its staff and residents and this was evident through the records viewed on the day of the inspection. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 x 3 3 3 3 3 x 3 3 3 David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 22 No Are there any outstanding requirements from the last inspection? 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 OP 8 Regulation 13(4) Requirement An action plan must be put in place for any resident where a risk has been identified during the assessment process. A documented risk assessment must be in place for all service users who undertake to selfadminister their own medication Timescale for action 30/06/05 2. OP 9 13(4)(b) 30/06/05 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 OP 9 Good Practice Recommendations It is recommended as good practice that when it is necessary to handwrite a medication administration record chart in the home that the member of staff writing the chart signs the chart and that a second carer checks the entry for accuracy and then initials the chart. David Gresham House H58 H09 s13622 David Gresham House v223860 160605 Stage 4 ann.doc Version 1.30 Page 23 Commission for Social Care Inspection 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. 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