Inspection on 10/10/07 for Surrey Heights

This inspection was carried out on 10th October 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

Surrey Heights 17/10/06

Surrey Heights 17/01/06

Surrey Heights 26/07/05

Surrey Heights 14/07/04

Surrey Heights 04/05/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Surrey Heights Surrey Heights Brook Road Wormley Surrey GU8 5UA Lead Inspector Suzanne Magnier Unannounced Inspection 10th October 2007 09:30 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 Surrey Heights DS0000013810.V348752.R01.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. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Surrey Heights Address Surrey Heights Brook Road Wormley Surrey GU8 5UA 01428 682734 01428 685061 eheath@carehomesofdistinction.co.uk 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) Mr L K Hasham Mrs N Hasham Michele Woodger Care Home 39 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (7), of places Physical disability over 65 years of age (2), Sensory Impairment over 65 years of age (4) Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom residential accommodation and personal care is provided at any one time shall not exceed THIRTY NINE (39) PERSONS 17th October 2006 Date of last inspection Brief Description of the Service: Surrey Heights is a privately owned care home offering residential care for thirty-nine older people with dementia. It is a large detached building in acres of mature south facing grounds on the crest of the Surrey Hills. The home is one of a number of others run by Care Homes of Distinction in Surrey. The Groups principal office is in the grounds of Surrey Heights and next door is Surrey Hills, a nursing home that is part of the group. Single and shared bedroom accommodations, some with en suite facilities, are arranged over three floors, accessible by passenger lift. Communal lounge, conservatory and dining facilities are on the ground floor. Parking is available in the grounds. The range of fees for the rooms is from £460 - £630. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Some additional standards were assessed and have been included within the report. Ms S Magnier Regulation Inspector carried out the inspection and the registered manager and a senior care staff member represented the service. For the purpose of the report the individuals using the service are referred to as residents. The inspector arrived at the service at 09.30 and was in the home for eight hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. The inspector spent time talking with people living at the home in order to seek their views about the home and the care they receive. Responses to questionnaires that the Commission had sent out and written comments have been included within the report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the home’s Statement of Purpose and Service User Guide, care plans, daily records and risk assessments, medication procedures, staff files, a variety of training records, and several of the service’s policies and procedures. The home had submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection, some details of which have been added to the report. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. The inspector would like to thank the people living in the home, the staff and the manager for their time, assistance and hospitality during this inspection. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Service User Guide must be updated to include information regarding fees. All records must be kept up to date to ensure the safety and well being of all residents in the home. The practice of leaving an unattended blister pack rack of medication on the medication trolley whilst staff are supporting a resident taking their medication needs to be risk assessed in order to ensure the safety and wellbeing of residents in the home. The home must ensure that all staff supporting residents at mealtimes are suitably competent and maintain good personal and professional relationships with residents. The home must ensure that accurate information is maintained with regard to the status of complaints received by the home. It is recommended that care plans be further improved to include a more person centred approach to reflect the individuality of the person receiving care and support in the home. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 7 It is recommended that the recording of end of life arrangements of people living in the home are more fully and accurately recorded to reflect peoples wishes and choices. It has been recommended that the home obtain written verification in the form of a checklist to verify that the relevant agents abroad have completed checks and the documentation is sent to the care home prior to prospective staff arriving in the UK in order to ensure the safety and protection of people living in the home. 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. Surrey Heights DS0000013810.V348752.R01.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 Surrey Heights DS0000013810.V348752.R01.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, 3, 6. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Prospective individuals have information about the home in order that they can make an informed choice about moving to the home. Information regarding the fees needs to be updated. The home’s admission and assessment procedures ensure that individual’s needs are appropriately identified and met. People are encouraged to visit the home prior to residency. EVIDENCE: The inspector sampled the home’s Statement of Purpose and Service User Guide. Both documents were well recorded and offered information related to the home. It has been required that the Service User Guide is updated to include information regarding fees. The complaints procedure within the Statement of Purpose did not include the current details of the Commission for Social Care Inspection (CSCI) and this was amended during the inspection. The manager and the inspector discussed ways in which the Statement of Purpose and Service User Guide could be available to individuals with diverse Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 10 needs, for example sensory impairment, and the manager advised that the written font of the documents could be enlarged in order that all individuals would have access to information in a format suitable to their needs. The manager also demonstrated an awareness that some individuals may find the documentation a cause of anxiety and therefore would be selective in the way information about the home is delivered. The home undertakes pre admission assessments in order to ensure that the home can meet the needs of the individual. It was evident through sampling care plans that assessments had been completed with the support from a relative or representative. The Annual Quality Assurance Assessmen (AQAA) explains that a persons orientation, memory, mental state and cognition are assessed and also includes assessements of risk such as anxiety, restlessness, resistance to care and severely disruptive behaviour. Relatives and prospective residents are invited to spend time in the home and are also given a well documented information pack/welcome pack which includes appropriate information, for example the routines of the home, meal times, activities, the care staff key worker system and details regarding the laundry service to inform prospective individuals or their representatives about the services provided by the home. The home does not provide intermediate care yet respite care is given provided there is a vacancy in the home. Surrey Heights DS0000013810.V348752.R01.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, 10, 11. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The health and personal care that people receive are based on their individual needs set out in their care plans. Risk assessments are maintained to ensure the safety of people in the home yet need to be signed and dated. Medication procedures ensure that medication is administered to all individuals in an appropriate way yet one practice must be risk assessed to ensure the safety and wellbeing of residents. People’s dignity and respect are promoted. The recording of end of life choices and preferences needs to be more fully developed. EVIDENCE: The inspector sampled three care plans which are the Standex model and developed from the individuals orginal care assessment. The care plans illustrated peoples differing care needs and how care and support were provided. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 12 The care plans were well documented to reflect peoples individualised personal care needs, condition of individuals skin/pressure areas, sleep patterns, accident and falls records, nutrition and diet, mobility, daily records of care provided and activities undertaken throughout the day, sensory impairments, emergency contact and body weight charts. Whilst sampling the care plans it was noted that reviews were being held and where necessary changes to the care plans were implemented to ensure that the changing needs of people in the home were recognised. The inspector and manager discussed ways in which the care plans could be further improved to reflect a more person centred approach which could include more details about the individuals identity, personality and communication, past occupation, their lifestyle history, hobbies, likes and dislikes and their aspirations and goals as it was recognised that the care plans were essentially task based. The manager acknowledged that this improvement and recommendation would benefit the individuals receiving care and support at the home. It was evident that the home is considering altering the care planning documentation as the inspector was shown documents which confirmed this. In addition whilst speaking with the activity coordinator the inspector was advised that they were compiling individuals life biographies and would be using a specialised activity assessment tool to ensure the activities offered are well matched to the individual. Evidence was available that residents were supported to access health care appointments and health care professionals visited the home. During the inspection a physiotherapist visited the home to offer encouragement and mobility to several residents. Other health care professionals involved in the care of residents included the general practitioners, dieticians, chiropodists, continence advisors, opticians, dentists and specialised health care professionals. Risk assesments were sampled and assessments included falls, nutrition and manual handling. The manager advised that where appropriate other risk assessments are completed with regard to any other activity that is observed to be hazardous to the resident. It was noted that the risk assessments sampled had not been dated or signed by the author and a requirement has been made that all records must be kept up to date to ensure the safety and well being of all residents in the home. During the inspection it was observed that although busy, there was a calm atmosphere throughout the home. Staff addressed people in a professional and caring manner. Individuals were addressed by their first or full name and Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 13 where appropriate names of endearment were used to support trusting relationships. Staff were observed to preserve and maintain peoples dignity and privacy by knocking on their room doors and waiting to enter, supporting people discreetly to the bathroom and being observant and attentive to people who were not fully able to maintain their own dignity. Whilst touring the premises the inspector noted that along the corridors the home had included visual aids to support people finding the toilets and their bedrooms. It was observed that one resident went into the bathroom/toilet, which was already being occupied by another resident. The inspector observed that there was no sign on the door to indicate that the room was occupied and following bringing this to the activity coordinators attention, several signs indicating ‘vacant and engaged’ were made by the residents and the activity coordinator to be displayed on the bathroom/toilet doors to help promote peoples rights to dignity and privacy. Written comments received by CSCI regarding the care at the home included: ‘The care home looks after people well’ ‘ if I’ve had any medical problems the staff are always helpful and thorough’ ‘my father seems very happy at Surrey Heights’. The home has a medication policy and procedure. The inspector sampled the medication trolley, which was stored securely within the home. The medication trolley was orderly, clean and was well stocked. A senior care staff member explained the procedures for the ordering, returns and stock taking of medicines in the home. The home has a monitored dosage system (MDS), which is supplied by the local Pharmacist. The deputy manager advised that only one resident self medicates and they are supported to maintain their independence and choice. The inspector sampled the medication administration records (MAR) charts, which were accurately completed by staff administering medication. The inspector was advised that no controlled drugs are currently being used in the home yet the senior care staff member explained the procedure for the safe storage and administration of controlled drugs. Staff training records indicated that regular training regarding the safe administration of medicines was undertaken. The inspector observed a senior staff member administer medications during the lunchtime. It was observed that the staff member left the blister pack rack on the top of the locked medication trolley whilst they were supporting a resident to take their medication. This observation was reported back to the manager and staff member who advised that this was the general practice and Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 14 in their view there were sufficient numbers of staff available in the area to ensure that the rack was not removed. It has been agreed that this practice is risk assessed in order to ensure the safety and wellbeing of residents in the home. Each care plan contained some documentation of the individuals end of life arrangements and included some relatives or significant others expectations of the home regarding the individuals end of life arrangements. It was noted that the documentation was not fully complete. The manager explained that this was an area of improvement, which would be worked upon in order to ensure that people’s wishes and choices are more accurately recorded with regard to their end of life arrangements. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 15 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, 15. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. People who use the service are able to exercise choice in their daily lives, maintain bonds with family and friends, and take part in social, cultural, religious and recreational activities. Staff engagement with residents at mealtimes needs to be improved. The home provides a healthy and balanced diet in a pleasant spacious dining area. EVIDENCE: The inspector spoke to a variety of residents and staff during the day all of which spoke highly of the activities and the general running of the home. It was noted that people were moving freely around the home, which included wandering in the conservatory and communal areas. Several people were observed reading the daily papers and chatting with other people in the home including staff. The inspector observed the residents enjoying their activities which included sculpting with paper, needlecraft, knitting, reading and doing crosswords. Several residents were going to the local secondary school to take part in a sculpture trail and a bus had been hired for the afternoon. One resident told the inspector how they like it when the man came to play the piano and Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 16 residents are involved in the planning and choices regarding meaningful activities if they choose to be. It was noted that the activities organisers fully engaged with residents and offered encouragement and support in a caring and sensitive manner along with banter with some residents, which they readily encouraged. The activities were undertaken in a separate room, which enabled residents to have a familiar setting and take part in the meaningful activities, which were close at hand. Written comments received by CSCI and comments received during the inspection regarding the social activities in the home were varied and included that ‘I’m too old to be taking part in activities’. ‘The home is lovely and the staff are kind’, ‘I like living here and have been here a long time.’ The home supports residents in their spiritual and religious beliefs and a communion service is held once every month with residents given the choice if they wish to attend. The AQAA received by the commission detailed that currently all residents were either practising or non-practising Christians. During the course of the inspection the managers and staff demonstrated that the home encourages and supports ongoing friendships and relationships. This was evidenced by the home supporting three couples in shared accomodation. Additional examples was the evidence of a policy for visitors to the home, the manager making time to meet with or speak to relatives with any comments or concerns they may have and offering formal reviews of their loved ones care. A relatives group has been set up by the home to offer support and an annual reunion lunch is also arranged in order to offer ongoing support for those people who wish to maintian links with the home. The manager demonstrated that she and the staff were aware of outside organisations which included supporting residents to the Alzheimers Society day service, maintaining links with the local community, for examle a neighbour came to the home on the inspector’s arrival to drop off magazines for the residents, and also the home plans to subscribe to the Care Aware advocacy service. During the inspection ‘minnie’ the pat dog arrived with her owner and the inspector observed that several residents responded favourably to her. One resident had commented that they would like to have a dog in the home and this comment was explored with the manager. The inspector observed the midday meal, which consisted of a hot roast lunch. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 17 As a measure of good practice the home have implemented a system which offers residents needing support with their meals to have theirs first and be supported on an individual basis by staff. Other residents who do not require one to one support have their meals following this arrangement and it was observed that staff were available to support people if they should need them. Residents spoken with generally enjoyed their meal. Meals were served by staff at a serving area within the main lounge and taken individually to residents in the conservatory/dining area. It was observed that residents were shown the meal on offer and a choice was available if they did not want to have the roast meal. Staff told the inspector that the menu is changed on a seasonal basis with people’s preferences taken into account. The AQAA received by the commission detailed that the home offers residents the option of having their meals in their rooms and people are given a choice of food at mealtimes and when they want or need to eat. This was observed as one resident did not want to have their meal and they were advised that they could have it later. Another resident chose to have several meals and told the inspector that the food was ‘lovely’. Whilst observing the lunchtime routines the inspector noted that the dining areas in the home were spacious and well decorated and offered adequate facilities for residents. It was brought to the manager’s attention following the lunchtime that one staff member was observed to show little or no interaction with residents, for example, laying the table with cutlery, pouring juice into plastic cups and placing protective aprons and meals in front of residents without speaking or engaging the resident in the activity. The manager expressed concern regarding this observation and it was identified that improvements need to be made regarding raising staff awareness of positive interaction and cultural expectations. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 18 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 a range of evidence including a visit to this service. People who use the service are able to express their concerns and have access to a complaints procedure. They are protected from abuse and have their rights protected. EVIDENCE: As previously documented the home’s complaints procedure was updated at the time of the inspection to include the current details of the Commission for Social Care Inspection (CSCI). The updated procedure was displayed in a prominent place within the home. No complainant has contacted the commission with information concerning a complaint made to the service since the last inspection. The AQAA details that three complaints have been received since the last key inspection. Whilst sampling the complaints log the inspector noted that improvements must be made to ensure that the log contains accurate information with regard to the status of complaints received by the home. It was acknowledged that the complaint in question had been fully investigated by the home. Written comments received by the commission regarding the home’s complaints process included that people associated to the home knew how to make a complaint and would approach the manager or staff at the home if they had concerns. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 19 The inspector sampled that the home has the local authorities multi agency procedures for safeguarding adults and the manager advised that the home follows these procedures. The AQAA details that there have been two safeguarding referrals under these procedures since the last inspection, one of which has been concluded. The inspector noted that the home has a whistle blowing policy and procedure, which is available to staff in order to safeguard people in their care. Staff spoken with during the inspection demonstrated an understanding of the procedures for safeguarding adults. Staff training records detailed that staff receive awareness training regarding safeguarding vulnerable adults. Where some staff had not attended the training plans were in place for the staff to attend the in house training in order to safeguard people in their care. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 20 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, 20, 22, 24, 26. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The physical layout and indoor and outdoor communal areas of the home enable people who use the service to live in a safe and well-maintained environment. Individual’s independence is promoted and maximised using specialist equipment. Individual’s bedrooms suit their needs. All areas of the home are clean and hygienic. EVIDENCE: During the tour of premises the inspector observed that the home was well maintained and the handy person employed at the home was undertaking some minor repairs. Several fire doors were not closing flush and these were repaired during the inspection. It was noted that in order to support people with impaired sight, spotlights had been placed at a flight of stairs to assist resident’s visibility and safety when using the stairs. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 21 The home’s indoor and outdoor communal areas were well maintained and appropriate access was available to all persons in the home. In order to ensure the safety and protection of residents it was noted that each exit of the home, not in general use, contained a sensory pad on the floor, which would alert the staff at the home that the exit door may have been opened. The inspector observed staff supporting residents using equipment in the home for example walking frames, hand rails, ramps and stairs and other mobility aids to assist people to safely move around the home. People spoken with told the inspector that they liked their bedrooms, which were comfortable. It was noted that people’s bedrooms were individualised and some contained their own items of furniture, personal possessions, leisure items including televisions, radios and books. All rooms were clean and free from malodour. The inspector was advised that the home has a cleaning plan, which is maintained on a daily basis. During the tour of the premises the inspector sampled the home’s kitchen and laundry area, which was orderly and clean. Other areas of the home were noted to be clean and hygienic throughout. The bathrooms, walk in shower and toilets throughout the home were clean and suitable to meet the assessed needs of the residents in their home. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 22 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, 30. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. The home has a robust system for the induction and training development of staff. Record keeping regarding staff recruitment needs to improve. EVIDENCE: The staffing numbers on the day of the inspection were observed to meet the current needs of the people living in the home. Written comments and comments received on the day of the inspection regarding the staff at the home included ‘The care home looks after people well’. ‘The staff have been very good when I need them’. ‘My relative enjoys the friendly staff and the activities’. ‘The staff are very caring and friendly’. The manager explained that the home employs a multi-cultural workforce and equality and diversity issues are addressed in the staffs induction programme. The inspector sampled two staff recruitment files. Both staff recruitment had been obtained via an overseas recruitment agency. One file sampled did not contain an application form and both references were photocopies and did not indicate that original references had been obtained. Whilst the inspector was Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 23 assured of the validity of the recruitment process it has been recommended that the home obtain written verification in the form of a checklist to verify that the relevant agents abroad have completed checks. In addition the documentation is sent to the care home prior to prospective staff arriving in the UK in order to ensure the safety and protection of people living in the home. This arrangement was agreed with senior management of the organisation following the inspection. The staff mandatory and induction training records were sampled and evidenced that the home is committed to the ongoing training and development of staff in order to ensure that the home’s staff are suitably trained and competent in their duties. The records indicated that all staff had undertaken the necessary mandatory training and where refresher courses were needed these had been identified through the accuracy of the record keeping. The inspector was advised that over 50 of staff had achieved their National Vocational Qualification (NVQ) in care some of whom were overseas nurses and training records sampled supported the information. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 24 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, 38. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The management and administration of the home are robust and the home is run in the best interests of people who use the service. Peoples’ safety, and welfare are promoted. EVIDENCE: The atmosphere in the home was calm and orderly. The pace of the home was designed to meet the needs of the residents and there was no sense of hurry. The manager advised that she had completed her Registered Managers Award. It was evident through observation and talking with residents and staff that the manager had good knowledge about managing the care home and had the Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 25 skills and experience to ensure the safety and well being of all persons in the home. People’s views about the service were actively sought and quality assurance procedures were in place to seek the views of people who use the service and any visitors to the home. The manager explained that the home is not involved in keeping residents money. The inspector sampled a variety of health and safety records, which included water, fridge and freezer temperatures, accident and incident records, fire practices and noted that the fire extinguishers had been serviced. The home’s policies and procedures promote the health, safety and welfare of people in the home. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 26 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 2 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X 3 X 3 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 3 Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 27 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 OP1 OP7 Regulation 5. (1)(bb) (bc)(bd) 17(3)(a) Requirement The Service User Guide must be updated to include information regarding fees. All records must be kept up to date to ensure the safety and well being of all residents in the home. The home must ensure that accurate information is maintained with regard to the status of complaints received by the home. Timescale for action 10/11/07 31/10/07 3 OP16 22.(3) 31/10/07 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 care plans be further improved to include a more person centred approach to reflect the individuality of the person receiving care and support in the home. It is recommended that the recording of end of life DS0000013810.V348752.R01.S.doc Version 5.2 Page 28 2 OP11 Surrey Heights 3 OP29 arrangements of people living in the home are more fully and accurately recorded to reflect peoples wishes and choices. It has been recommended that the home obtain written verification in the form of a checklist to verify that the relevant agents abroad have completed checks and the documentation is sent to the care home prior to prospective staff arriving in the UK in order to ensure the safety and protection of people living in the home. Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House, 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 Surrey Heights DS0000013810.V348752.R01.S.doc Version 5.2 Page 30 - 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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