Inspection on 27/09/05 for Eastbury Manor

This inspection was carried out on 27th September 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

Eastbury Manor 18/04/07

Eastbury Manor 11/05/05

Eastbury Manor 20/10/04

Eastbury Manor 26/05/04

Similar services:

The Shelley

Springfield House

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 Eastbury Manor The Street Compton Guildford Surrey GU3 1EE Lead Inspector Janet Daulton Unannounced Inspection 27th September 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 Eastbury Manor DS0000017608.V254834.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. Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Eastbury Manor Address The Street Compton Guildford Surrey GU3 1EE 0113 381 6100 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) eastburymanorall@bupa.com BUPA Care Homes Limited Srijit Duffadar Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. In respect of up to 5 service users receiving short-term respite or convalescent care, the age range may be from 50 years and over. Of the 33 beds in this home, up to 5 beds may be used for short-term respite or short-term convalexcent care. In respect of this service, Service users may be admitted from the age of 60 years. 11th May 2005 Date of last inspection Brief Description of the Service: Eastbury Manor Nursing Home is a substantial detached property that has been converted to provide nursing accommodation for up to thirty-three service users. The home is owned by BUPA Care Homes. The home is located in the village of Compton, near Guildford, Surrey. The home is arranged on two floors with a lift access. 22 of the rooms are for single occupancy, nineteen of which have ensuite facilities. There are two double rooms with ensuite facilities. The home is situated in extensive grounds of seven and a half acres with lawned areas and a large lake. Car parking facilities are available in the grounds. Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, and the second in the inspection programme for 2005-2006. The inspection took place over 4 hours, and was undertaken by Janet Daulton, lead inspector for the service. Mr Srijit Duffadar, the Registered Manager was present throughout the inspection process. A tour of the premises took place. The inspector spoke with 9 service users and one visitor during the inspection. Care plans, the complaints log, and a sample of safety certificates were sampled and examined. This was overall a positive inspection. The inspector wishes to thank the staff and service users for their time, assistance and hospitality during this inspection. To get a full overview of how the home is meeting the National Minimum Standards it will be necessary to read both inspection reports for the year 2005-2006. What the service does well: The home continues to provide a homely and attractive environment for the service users. The staff were seen to be caring for the service users in an open but respectful way. All service users contacted stated that they felt safe and well cared for in the home. Service users were encouraged to maintain control over their daily life as much as possible. The service users care plans were detailed. They gave clear instructions to the staff about the service users needs and the care that had to be given to meet those needs. An experienced activities coordinator organised the activities and entertainment well, providing good opportunities for service users to take part in activities. The home had a stable team of staff who knew the service users well. Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 6 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. Eastbury Manor DS0000017608.V254834.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 Eastbury Manor DS0000017608.V254834.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): The systems in place in the home ensured that all service users were assessed before admission to make certain that the home could meet the needs identified at that assessment. The home reviewed each placement when circumstances changed, to confirm that they were continuing to meet the needs. EVIDENCE: There have been no changes to the Statement of Purpose and Service User Guide. Prospective service users are assessed by the Manager or Deputy Manager before admission, and assessment forms were seen at inspection. This ensured that the home could meet the needs before the service user moved into the home. Respite care is offered but not intermediate care. Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 9 Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 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): 7,8,11 The service users health, personal and social needs were set out in an individual plan with all the needs clearly identified and there was documentary evidence of the identified needs being met. EVIDENCE: Service users and one visitor spoken with were complimentary about the care that they received at the home. All stated that they were comfortable in the home and that the staff were kind and caring. Care plans were sampled and examined at inspection. There was a very detailed assessment, and a care plan generated from that assessment, and evidence that the care plan was drawn up with the involvement of the service user or relatives. The care plan included appropriate risk assessments. There was evidence of review of care plans. Some of the risk assessments had not been regularly reviewed. There was also a summary of the care plan in each service users room. These were seen to be an accurate summary of the main care plan, however it is Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 11 recommended that these are signed monthly as evidence that they are regularly checked. Staffs were observed treating the service users in a friendly, but professional way. There were no service users with pressure sores at the time of the inspection. The home had adequate equipment to provide care for service users with pressure sores, Records were kept of any untoward incidents and any incidents where service users were admitted to Accident and emergency Departments. The home had policies and procedures for the arrangements and care to be provided when a service user is dying or has died. A recommendation was made that staff receive specific training in palliative care. Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 The social and recreational activities were varied and appropriate to enable the service users to maintain their interests. Service users were encouraged to maintain contact with their families and friends. EVIDENCE: There was an activities coordinator in post, who compiled a full and varied programme of events. A full assessment of the service users interests and previous experiences was completed by the activities organiser. Information about the activities offered was displayed on the notice board. Service users confirmed that they were able to join in the activities or abstain if they wished. Visitors were able to call at any reasonable time. Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 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 Service users are protected by the homes procedures for dealing with complaints EVIDENCE: The home had a clear complaints procedure, and a detailed complaint log was kept. There have been three complaints made to the home since the last inspection. The complaints were seen to be dealt with in an appropriate manner. The CSCI has also received one complaint which was upheld, and action has been taken by the Registered Manager. Service users spoken to were aware of whom to complain to. Staff had received training in vulnerable adults procedures and awareness, and there was an adult protection procedure in place. Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 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): 19,20,22,26 The location and layout of the home was suitable for its stated purpose. The call bell arrangement was not satisfactory in the lounge area, putting the service users in there at risk. Action was taken to address this matter. EVIDENCE: During a tour of the home the premises were seen to be well maintained with service users able to access all areas of the home and gardens. The premises overall were clean, however one area had a malodour, and this was brought to the attention of the Manager for action. The home was fitted throughout with appropriate aids and adaptations, including assisted baths. Grab rails were fitted in hallways, and in bathrooms and WCs. There was a passenger lift and also a chair lift. There were sufficient openings in doorways to allow the passage of a wheelchair. There were call bell systems in the home. The call bell system in the lounge area was inadequate, as service users who had mobility problems were unable to access Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 15 the call bell. Prompt action was taken by the Registered Manager following the inspection to address this matter. Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 16 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 numbers and skill mix of the staff met the service users needs. Service users were protected by the homes procedures for recruitment. Staff receive training to enable them to care for the service users in a skilled way. 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. Service users commented that staff answered the call bells within a satisfactory time, day or night. Domestic and laundry staff were employed in sufficient numbers. All interactions observed between staff and service users during the inspection were seen to be caring and respectful. Staff files were examined. All necessary checks had been completed prior to employment. There are six Care Assistants employed in the home. Four of these staff have attained level 2 or 3 NVQ. The home had a high number of qualified nursing staff working on each shift. An induction programme was in place for new members of staff. Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 17 Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 18 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): 32, 35, 38 The home was well managed by the Registered Manager, who was aware of his responsibilities to service users and staff. All safety certificates must be in place to ensure the well being of service users. EVIDENCE: The Registered Manager has the qualifications and experience to manage the home. There were clear lines of accountability within the home. Service users financial interests were safeguarded by the homes policies and procedures. The majority of staff had received appropriate training in health and safety matters, including moving and handling and fire training. New members of staff had a date for health and safety training. Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 19 The electrical testing certificate was not available at inspection. Written Confirmation that the electrical certificate has been issued is to be sent to the CSCI. Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x 2 x x x 2 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 x x 3 x x 2 Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 21 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 2 Standard 7 22 Regulation 15(2) 12(1)(b) Requirement Risk assessments in the care plans must be regularly reviewed. A risk assessment must be completed about access to a call bell in the lounge area, and action taken if service users cannot access the bells. The risk assessment and action taken must be forwarded to the CSCI All areas of the home must be free for malodour. The Registered person must send written confirmation to the CSCI that an electrical certificate has been issued. Timescale for action 31/10/05 30/09/05 3 4 26 38 16(2)(k) 13(4)(a) 27/09/05 14/10/05 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 7 Good Practice Recommendations The summary of the care plan in each service users room is signed monthly as evidence that it is has been checked DS0000017608.V254834.R01.S.doc Version 5.0 Page 22 Eastbury Manor 2 11 against the main care plan. Staff receive specific training in some aspects of palliative care Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 23 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 Eastbury Manor DS0000017608.V254834.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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