Inspection on 30/08/07 for Hendford Nursing Home

This inspection was carried out on 30th August 2007.

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 22/01/07

Hendford Nursing Home 29/11/05

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 Mary Williamson Unannounced Inspection 30th August 2007 10:20 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.V345804.R02.S.doc Version 5.2 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.V345804.R02.S.doc Version 5.2 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.V345804.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd January 2007 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. Fees range from £550-£650 per week. This fee does not include hairdressing, newspapers or transport. This information was provided on 30/08/07. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. The inspection took place over five and a half hours. Mary Williamson, who is a regulation inspector, carried out the inspection. The registered manager, Maria Christopher, represented the establishment. A tour of the premises was undertaken and a number of records relating to the care of the residents and the management of the home were examined. It was possible to meet most of the residents and talk with some of them in more detail than others. It was also possible to speak with relatives visiting the home during the inspection. The manager completed an AQAA (Annual Quality Assurance Assessment) prior to the inspection. Resident and relative feedback survey forms were also returned to the to the inspector prior to the inspection. Equality and diversity is observed and diverse needs of residents recorded in care plans. There have been no complaints since the last inspection. The Commission for Social Care Inspection would like to thank the residents, relatives and the staff team for their help and hospitality during the inspection process. What the service does well: The home provides good quality care and support for residents based on comprehensive needs assessments. Residents’ comments included, “I am happy here but it is not like being at home”, “ The staff are very kind” and “The food is lovely”. There are satisfactory arrangements in place to meet health and emotional needs of individual residents and the home has the input of the local mental health team and two psychiatrists for support. The home has recently engaged the support of the local Alzheimer’s Society to promote specialist activities in the home, and provide training for staff. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 6 The catering arrangements in the home are good and residents’ nutritional needs are met. Special diets are catered for and drinks and snacks are available throughout the day. What has improved since the last inspection? What they could do better: Individual contracts of occupancy are in place. However, these must be reviewed to outline the type of room to be occupied, for example single, shared or en-suite. Contracts must also outline the fees payable and by whom. Care plans are well maintained, but could include a more detailed social history, which would be beneficial in the improvement of individual activity programmes. The bedroom doors on West Wing have small glass windows, which the manager stated was for the purpose of observing residents in their rooms. A requirement has been made for blinds or curtains to be provided to these windows to promote privacy and dignity whilst personal care is being undertaken. The manager must record any incidents that take place in the home and report this to the Commission for Social Care Inspection in accordance with Regulation 37. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 8 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.V345804.R02.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 6. Quality in this outcome area is good. his judgement has been made using available evidence including a visit to this service. Residents and their relatives have access to sufficient information in order to help them make a decision about the home. Contracts of occupancy and needs assessments are in place. The home does not provide intermediate care. EVIDENCE: There is a statement of purpose and service user guide in place and a copy of this is also kept at the main reception area. All prospective residents, relatives or designated representatives have access to a copy of this in order that they can make a choice about choosing the home. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 10 Contracts of occupancy are in place and outline the fees payable and who is responsible for the payment of these. Contracts must be updated to provide details of the type of accommodation offered, for example if a room is single, shared or provides en-suite facilities. A prospective resident has a needs assessment undertaken prior to admission. The clinical manager or a qualified nurse carries out this assessment. A multi-disciplinary meeting then takes place to establish the care needs of the resident and if the home can meet these assessed needs. Four needs assessments were randomly sampled which were well documented and informative. The home does not provide intermediate care. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are outlined in individual care plans. Social care needs could be more detailed. The arrangements in place to meet the health care needs of residents are satisfactory. The medication procedure in place protects the residents. EVIDENCE: Individual care plans are in place. These are well written, based on the pre-admission needs assessment, input from the resident whenever possible, information obtained from relatives and care managers and any other relevant medical reports. Four care plans were randomly sampled, and were well maintained, informative and reviewed on a regular basis. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 12 All the residents are registered with a local GP who visits the home weekly or more frequently if required. The manager stated that the home also has access to the Mental Health Team at West Park Hospital, and to the Community Psychiatric Nurse. Two psychiatrists also visit the home. The manager stated that there are frequent audits of care from the PCT due to the free nursing care contributions. The dentist visits the home regularly and the dental hygienist was in the home during the inspection. Chiropody is provided every six weeks and the optician will also visit when necessary. Privacy and dignity is respected and staff were observed to interact with residents in a polite and respectful manner. Screens are provided in shared rooms. The West Wing is a purpose built extension for residents with dementia. It was noted that all the bedrooms had a small window for the purpose of observing residents whilst in their room. However, these windows need to be fitted with a curtain or blind in order that personal care can be carried out behind closed doors in private. A requirement has been made accordingly. The home has a medication policy in place and all staff administer medication according to this policy, and in accordance with the NMC (Nursing and Midwifery Council) Code of Professional Conduct. Medication is stored in the clinic room, which is well organised and equipped. Pastons, the chemist, provide all the medication for the home and also undertake regular audits of medication. The medication recording charts were sampled and are well maintained. The management and storage of controlled drugs is good and the records correct. Qualified staff administer medication and their training is updated at Epsom General Hospital or at St Georges Hospital. Currently no resident in the home self medicate. Equality and diversity is observed and the diverse needs of residents are included in individual care plans. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides activities for residents according to preference and ability. Family links are maintained. The nutritional needs of residents are met. EVIDENCE: Activities are provided and the home engages the help of two activity organisers to oversee some of these activities. The manager stated that an “old time music” session is provided weekly and every Saturday morning somebody comes to play the piano for the residents. Other activities include jigsaw puzzles, bowling, skittles and ball games. Records of activities are kept on completion. During the inspection two outreach representatives from the Alzheimer’s Society were visiting the home with a view to providing training for staff and activities for residents. Family links are maintained and visitors are welcome in the home at any reasonable time. There was an opportunity to talk with several relatives during the day and all were happy with the home and the support provided. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 14 Spiritual needs of residents are observed and the manager explained how the local Baptist Church visits to offer support and talk to the residents. The home also welcomes visits from various local clergy, and regular services of worship are organised. Menus are planned by the manager with the help of the chef and input from residents, whenever possible. Lunch was observed and residents were enjoying homemade sausage pie, fresh vegetables and potatoes, followed by rice pudding. Sensitive support was offered to residents who required feeding. Positive feedback was received regarding the standard of catering and residents stated that ‘the food is always good here’ and another resident stated, “We get plenty to eat here”. Special diets are catered for to meet the medical and cultural needs of residents. The kitchen was visited and was well managed and orderly. All staff who handle food have a current food hygiene certificate. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure and abuse awareness procedures in place protect residents living in the home. EVIDENCE: The home has a complaints procedure in place that is available to all residents and their relatives and is included in the service users’ guide. The home also has a ‘Whistle Blowing’ policy in place and basic awareness of the safeguarding of vulnerable adults is included in the home’s induction training. A copy of the latest Surrey Multi-Agency Procedure for the Safeguarding of Vulnerable Adults is available in the office. Staff spoken to were aware of the abuse awareness procedures and said that they would report any suspicion of abuse to the nurse in charge. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home and gardens is suitable for the stated purpose. Residents live in a comfortable, homely and clean environment, which meets their individual and collective needs. EVIDENCE: The home is decorated to a good standard, providing residents with a comfortable, homely and well-maintained atmosphere to live in. The communal areas of the home include two lounges and a dining room, which are all comfortably furnished. Residents have access to a well-maintained garden to the back of the home. Residents’ accommodation is provided in single and shared rooms. Most of the bedrooms have been personalised to reflect individual interests and hobbies. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 17 The bedroom doors on West Wing have small glass windows for observation. A requirement was made under Standard 10, relating to privacy and dignity, for curtains or blinds to be provided for these doors whilst personal care is being carried out. Several bedrooms (5, 6, 7, 8, 9,11 and 12a) on this wing had damaged walls from armchairs banging against them. These need to be repaired and repainted. The standard of cleanliness is good and relatives made positive comments regarding the home “always being clean”. The laundry facilities are suitable to accommodate residents’ needs. The home has an infection control policy in place and staff are made aware of this policy during induction training. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the number and skill mix of staff. The training and development of staff and the recruitment procedures protect the residents in the home. EVIDENCE: The staff duty rota was seen and indicated that sufficient staff were on duty to meet the assessed needs of the residents. The home also employs a team of ancillary staff including a housekeeper, chef, kitchen assistant, maintenance staff and an administrator. The training and development of staff is ongoing. All staff undertake an induction programme. Currently there are over 50 of staff with an NVQ Level 2 or Level 3 award in Care. Two staff spoken to stated that they were due to undertake this training next month. The home is also a teaching environment for student nurses in their third year on nurse training. The Nursing and Midwifery Council has approved the home for this purpose, and is linked to Kingston University as a learning centre. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 19 Relatives commented that the staff are helpful and kind. Several staff working at the home have English as their second language and relatives commented that this can make communication difficult at times. This was discussed with the manager who confirmed that English classes are provided by NESCOT College. These classes are provided in the home and include Pitman Level 1 and Level 2 Spoken and Written English. There is a recruitment policy in place, which has improved since the last inspection. Three staff employment files were sampled and are well maintained. Each file had the required documentation in place including written references, an employment history and a CRB (Criminal Record Bureau) reference number in place. One file had only one written reference in place. A requirement has been made accordingly. Staff confirmed that they had been issued with a job description and contract of employment. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by an experienced manager in the best interests of the residents. The home promotes the health, safety and welfare of residents and staff. EVIDENCE: The home is well managed by an experienced manager who has completed her Registered Managers Award. She operates an open and inclusive style of management and both relatives and staff commented that they felt well supported by her and the management team. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 21 There is also a clinical nurse manager in post who is a qualified nurse with RMN qualification. He is supported by a team of qualified nurses, two of whom are undertaking NVQ Level 4 in Management. Appropriate systems are in place to monitor quality assurance. Staff meetings take place and residents’ views are sought whenever possible. Surveys are sent to relatives, care professionals, GP’s and care managers for feedback. Results are analysed and a report published regarding the strengths and weaknesses identified. The home also has regular audits by Kingston University, as it is a student nurse-learning environment. No valuables are kept in the home and any money spent by the residents for sundries, for example newspapers, toiletries and hairdressing is invoiced on a monthly basis. Health and safety is promoted and risk assessments are in place for all identified risks and safe working practices. Fire safety arrangements in place include yearly fire safety training for staff. There is a contract in place for the maintenance of fire fighting equipment and the emergency lighting system. Accidents and incidents are recorded appropriately. However, during the inspection it was disclosed that a signefient event was not reported to the Commission in accordance with Regulation 37. A requirement has been made accordingly. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 22 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 23 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 OP2 Regulation 5(1)(b) Requirement The registered person must ensure that contracts of occupancy include the type of accommodation provided and amount of fees payable. The registered person must ensure that provision is made to respect the privacy and dignity of residents. Therefore blinds or curtains must be provided on the bedroom doors in West Wing to ensure that personal care can be provided in private. The registered person must ensure that all parts of the care home are kept in a good state of repair. Therefore the bedrooms on West Wing identified in the report must have the bedroom walls repaired and repainted. The registered person must not employ a person to work in the care home unless he/she is fit to be employed. Two written references must be obtained and available on file for inspection. DS0000013326.V345804.R02.S.doc Timescale for action 30/09/07 2 OP10 12(4)(a) 30/09/07 3 OP24 23(2)(b) 30/09/07 4 OP29 19(1)(b) Schedule2 30/09/07 Hendford Nursing Home Version 5.2 Page 24 5 OP38 37(1)(e) The registered person must give notice to the Commission of any event in the care home which adversely affects the well-being or safety of the residents. 30/09/07 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 OP7 Good Practice Recommendations It is recommended that the home carry out a review of service user care plans and include all social history available. This can then be used to elaborate on the social care activity needs of the residents. Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Hendford Nursing Home DS0000013326.V345804.R02.S.doc Version 5.2 Page 26 - 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. 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