Inspection on 29/11/05 for Hendford Nursing Home

This inspection was carried out on 29th November 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

Hendford Nursing Home 30/08/07

Hendford Nursing Home 22/01/07

Hendford Nursing Home 07/06/05

Hendford Nursing Home 11/08/04

Hendford Nursing Home 20/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hendford Nursing Home Howell Hill Grove East Ewell Epsom Surrey KT17 3ER Lead Inspector Lesley Garrett Announced Inspection 29th November 2005 08:00 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 Hendford Nursing Home DS0000013326.V251848.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. Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hendford Nursing Home Address Howell Hill Grove East Ewell Epsom Surrey KT17 3ER 020 83937891 020 83932886 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) Jesyem Medicare Limited Mrs Maria Christopher Care Home 34 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (34), Mental disorder, excluding learning of places disability or dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (34) Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Of the residents accommodated, up to 34 may fall within the category of either DE(E) or MD(E) Up o 3 residents may fall within the category of either DE or MD. The age range will be: over 65 years with up to 3 under the age of 65 but not below 59 years of age. 7th June 2005 Date of last inspection Brief Description of the Service: Hendford is a large detached house in the village of East Ewell. It offers accommodation with nursing for thirty-four older people with dementia and mental health needs. There are two large lounges for service users use. Accommodation is arranged over two floors with the majority of twenty single en-suite bedrooms and seven shared bedrooms. There is an enclosed garden at the rear of the house, which is accessible to the service users, and patio furniture is available in the good weather. Car parking is available at the front of the house, which has been extended during the refurbishment programme. Hendford Nursing Home DS0000013326.V251848.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 three hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. Lesley Garrett, Lead Inspector for the Service, carried out the inspection. Maria Christopher, Registered Manager, represented the establishment. A full tour of the premises took place. The inspector saw most of the residents but due to their mental frailty was unable to talk to any in depth. The inspector also spoke with the Proprietor Mr Kumar. A pre-inspection questionnaire and a number of returned ‘comment Cards’ were also used to write this report. This was a positive inspection. The inspector would like to thank the residents, manager and staff for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? Following the inspection on the 7th May 2005 no requirements were made. Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 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. Hendford Nursing Home DS0000013326.V251848.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 Hendford Nursing Home DS0000013326.V251848.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): EVIDENCE: Core standards covered at last inspection on 7th May 2005. The home does not have intermediate care beds. No concerns at this inspection. Hendford Nursing Home DS0000013326.V251848.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): 11 Resident’s and their families are treated with respect and sensitivity at the time of their death. EVIDENCE: At the pre-admission meeting which will involve the manager, the care manager and the next of kin death and dying is discussed openly and any wishes can be made known at this time and this is then documented in their individual plan of care. The G.P. also likes to speak with the families to assess their views on active treatment and resuscitation. The manager stated that when a resident is in the terminal stages of their illness they are often nursed on a one to one basis and this gives comfort to the families. Everything about that resident is the documented to show when they were last turned, washed, took fluids and saw the G.P. Everything is recorded during these last hours and the manager stated that occasionally the relatives read these notes and they are reassured that their family member was not alone during this time if they cannot be with them and that the death was peaceful. Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 10 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): 14 Resident’s exercise some control over their lives. EVIDENCE: Due to the mental frailty of the resident’s they do not handle their own finances and this is something the families or representatives deal with. However they are able to exercise choice with their food and this is done on the day, as the resident’s would have difficulty remembering what they have ordered. Choice is also made about what times they get up in the morning and go to bed. If they want to have breakfast in their pyjamas they can do so. The home does not have a set time for the residents to get up and they are not woken. The inspector looked around the home and found that a lot of the resident’s had their own possessions in their room and there was a memory book for them. Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: All core standards covered at the last inspection. No concerns. Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 12 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): 24 There has been no change to the décor or furnishings on the first floor in the last twelve months and although this does not pose a risk to the resident’s it does not create a pleasing and pleasant environment to live in. EVIDENCE: On the first floor the rooms are shared and this accommodation is now requiring refurbishment and redecoration. This was discussed with the manager who stated that one room was due to be made into two single rooms and they were waiting for this work to be completed before decorating the other rooms. The upstairs rooms were like this during the May inspection and this problem should now be addressed to start the refurbishment early in the New Year. This will be a requirement at the end of the report for the registered persons to send an action plan to the Commission with their proposals. Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 13 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): 28 NVQ training is taking place but there will not be 50 of care staff finished by the end of 2005. EVIDENCE: The manager stated that the home has fifteen carers and of these two have level 2 NVQ, two have level 3 and six are doing the course now with Kingston Hospital. The home will not have 50 of their staff with this qualification by the end of this year therefore there will be a requirement at the end of the report for the hoe to provide an action plan to show when this will be completed. The home does not use agency staff. All trainees are registered on the TOPPS-certified training programme. Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 14 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 & 35 A suitably qualified person manages the home and resident’s financial interests are safeguarded. EVIDENCE: The manager who is in the process of doing her RMA runs the home and this should be completed in about two months. She is not a registered nurse but has a clinical manager and there is always a RMN on duty during a twenty-four hour period. The only nurses who are left in charge of the home are those with dementia training. All registered nurses report to the clinical manager who in turn meets with the manager so she knows what is happening. No valuables are kept in the home any money that is spent by the residents can then be invoiced every month. The manager stated that at the preadmission meeting this is discussed so the relatives are aware. Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 15 Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 16 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X 2 X X STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X X Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 17 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 OP24 Regulation 16(2)(c) Requirement The registered persons to ensure that the first floor bedrooms are refurbished so they are the same standard as downstairs. Please provide an action plan to the commission to show the timescale for these works to start. The registered provider to ensure that visits take place in accordance with this regulation. The registered persons to provide an action plan to the Commission to explain how they will meet the 50 NVQ target for 2005. The registered persons are to ensure that fire risk assessments are in place for the rooms that require doorstops to ensure the residents safety. Timescale for action 29/12/05 2 3 OP32 OP28 26 18 29/12/05 29/12/05 4 OP38 16(2)(c) 06/12/05 Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 18 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 Hendford Nursing Home DS0000013326.V251848.R01.S.doc Version 5.0 Page 19 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. 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