Inspection on 07/06/05 for Hendford Nursing Home

This inspection was carried out on 7th 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

Hendford Nursing Home 30/08/07

Hendford Nursing Home 22/01/07

Hendford Nursing Home 29/11/05

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 Unannounced 07 June 2005 10:00 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. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 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 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 Howell Hill Grove, East Ewell, Epsom, Surrey, KT17 3ER Mrs Maria Christopher Care home with nursing (N) 34 Category(ies) of Dementia - over 65 years of age (DE(E)), 34 registration, with number Mental Disorder, excluding learning disability or of places dementia - over 65, 34 Dementia (DE), 3 Mental Disorder, excluding learning disability or dementia (MD), 3 Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Of the residents accommodated, up to 34 may fall within the category of either DE(E) or MD(E) 2 Up o 3 residents may fall within the category of either DE or MD. 3 The age range will be: over 65 years with up to 3 under the age of 65 but not below 59 years of age. Date of last inspection 11 August 2004 Brief Description of the Service: Hendford is a large detached house in the village of East Ewell. It offers accomodation with nursing for thirty-four older people with dementia and mental health needs. There are two large lounges for service users use. Accomodation 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 H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for the 2005/2006-year and was unannounced. The inspector was made to feel welcome by the manager and all her staff, which created a positive atmosphere in the home. The home is light and airy especially in the new west wing where the ceiling is totally glass and the sun was shining through. The inspector spoke with some service users’ and staff. There were no visitors during the time the inspector was there. The inspector would like to thank the manager and all those who participated in the inspection for their assistance. What the service does well: What has improved since the last inspection? There was one recommendation from the last inspection to explore provision of NVQ training for the carers. The manager told the inspector that the home now had accreditation to Kingston University to provide student nurse placements and also NVQ training provided by Kingston Hospital. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.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. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.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 Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.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) 3 All prospective service users have a pre admission assessment and good communication involving all parties. EVIDENCE: The clinical manager or senior registered nurse does all the pre admission assessments. The manager stated that the admission process could last for six weeks. The manager has a meeting with the relatives and care manager prior to admission and again after six weeks to check that the care being delivered is what has been promised or expected. The manager stated that this helps with settling in the service user to the home and families are welcomed. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 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 standard(s) 7,8,9 & 10 The home has a key worker system for reviewing all nursing notes and the medication is well managed promoting good health. EVIDENCE: The home has good nursing paper work, which has a variety of care plans and risk assessments. The home operates a key worker system with the registered nurses responsible for updating all the care plans. The G.P. visits the home weekly and will visit all service users that the registered nurses have put in his visit book and anyone else on request. The G.P. also reviews all medication on a monthly basis ensuring that no service user is over medicated. The inspector looked in the medicine cupboard and there was very little excess stock. The homes pharmacist also visits on a regular basis to do audits. The chiropodist calls every two months and the home also has domiciliary dentists who call two monthly and on demand and the opticians who come at the same intervals. The manager told the inspector that two service users had their own room key but that staff could also have access if necessary and the inspector witnessed staff knocking on the doors prior to entering The shared rooms had curtains dividing the space for privacy and dignity. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 Page 10 Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 Page 11 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 & 15 Activity provision is good with family and friends welcomed to the home. The dietary needs of the service users are well catered for EVIDENCE: The home has a full time activity organiser and they also use Activity Professionals who visit three times a week. The outside organisers mostly focus on physical activities like exercises and games of skittles. The homes activity organiser makes up the care plans then all activity people keep a record of the activity and who attended. The home organises outside entertainers who come weekly for singing. The local church choir visits about there to four times a year and a children’s choir also visits. The local vicar will also visit anyone who expresses a need. Families and friends are welcomed to the home the manager stated that in the first few weeks of admission it is essential they visit as often as possible so they can all get to know one another and build trust. The inspector spoke with the chef who works Monday to Friday and has another chef at weekends He was busy preparing the lunch and the manager explained that they have some service users who require a soft or pureed diet and these can be catered for. The chef had four-week menu rotas and he showed the inspector his daily fridge temperatures. The chef is helped with a kitchen assistant. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 Page 12 On the day of inspection the inspector noticed the staff going around serving cold drinks. One carer told the inspector this is usual practice even if the weather is not warm. They try to encourage extra fluids especially for service users that may have an infection. The carer told the inspector that this information is given at report. The manager stated that in the afternoon a tray of fresh fruit is prepared and the service users seem to enjoy this. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 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 standard(s) 16 & 18 Staff has knowledge of the Adult Protection issues and the home has a comprehensive complaints procedure. EVIDENCE: The complaints procedure is on the wall in reception and it is also in service user guide. The manager also explained that the procedure is explained to all prospective service users during the admission process. The complaints procedure contains details of CSCI. The manager stated that there had been no complaints since the last inspection. The manager stated that the home had the February 05 copy of the Surrey multi agency abuse policy. Two members of staff had attended the Surrey training and were then doing the training in the home. The home also has outside trainers to visit the home every three months for abuse training. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 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 standard(s) 19 & 26 Recent refurbishment has improved the appearance of this home creating a comfortable safe environment. EVIDENCE: The home has a maintenance man but the manager stated that the architect makes regular visits to check for any problems and then advises on any maintenance required. The new west wing with its glass ceiling allows light to flood in and the long straight corridor gives another access to the outside for the service users. New carpets have been ordered for the west wing. The gardener visits weekly to cut the lawn and maintain the flowerbeds. More flowerbeds have been organised the manager said the gardener was about to organise this. On the day of inspection it was a sunny day and some of the service users were outside. They have free access to the gardens and furniture is also available. One service user told the inspector that he enjoyed it outside and wanted a particular member of staff to stop what she was doing and to come outside with him. There was no offensive smells. Bedrooms were neat and tidy. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 Page 15 Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 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 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) 27,29 & 30 Staff morale was high resulting in an enthusiastic workforce that was working in a positive manner. EVIDENCE: On the day of inspection there were two trained nurses and five carers the registered manager was also present. The trained nurses assist in all aspects of the service users care and are there to supervise the carers also. The staff was welcoming to the inspector and willing to talk. One carer told the inspector this was her first job as a carer but she really enjoyed it and the training she had done so far manual handling, first aid and food hygiene. The manager stated that they were now linked to Kingston University as a centre for learning and this allowed them to have student nurses at the home on placements. Kingston hospital was now providing NVQ training and some sessions was held at the home and some at the hospital. Six carers are doing NVQ level 2 and two are doing level 3. The clinical manager who spoke to the inspector is coming towards the end of his RMN training at Epsom hospital, which he said he has enjoyed. A sample of recruitment files was looked at and they all contained the necessary information required. The manager showed the inspector the current training programme and stated that training took place every month on a variety of topics. The Nursing and Midwifery Council has approved the home as a learning environment. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 Page 17 The manager stated that she also has links with NESCOT to provide a spoken English course for all staff where English is not their first language. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 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 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) 33 & 38 The manager is supported by her senior staff, which leads to a relaxed, happy atmosphere. She seeks the opinions of families and visiting professionals. EVIDENCE: The manager stated that she does questionnaires yearly to the relatives and visiting professionals. She stated that they had a high response to these surveys and the inspector was shown some of the replies. The visiting lecturer from Kingston hospital was very complimentary about the environment for his students. The service users are unable to complete the questionnaires but the inspector noticed happy faces and appropriate responses to the inspector. All health and safety measures are in place. Fire alarms are tested weekly and the equipment is maintained by outside contractor. They visit twice a year and on demand. There are two first aid boxes kept in the kitchen and clinical room. Both the lift and boilers are maintained on a regular basis and have certificates. Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 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 x x 3 x x x x 3 Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 Page 20 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 Regulation Requirement Timescale for action 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 Good Practice Recommendations Hendford Nursing Home H09 H58 S13326 Hendford Nursing Home V230377 070605 Stage 4.doc Version 1.30 Page 21 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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