Inspection on 17/01/06 for Surrey Heights

This inspection was carried out on 17th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 10/10/07

Surrey Heights 17/10/06

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 Lesley Garrett Unannounced Inspection 17th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 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.V266612.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Surrey Heights Address Surrey Heights Brook Road Wormley Surrey GU8 5UA 01428 682734 01428 685055 g.john@carehomes.freeserve.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.V266612.R01.S.doc Version 5.1 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 14th July 2004 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 accommodation, some with en suite facilities, is arranged over three floors, accessible by passenger lift. Communal lounge and dining facilities are on the ground floor. Parking is available in the grounds. Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three and a half hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. Lesley Garrett Lead Inspector for the service carried out this inspection and Irene Voice senior care assistant and Anna White administrator represented the establishment. A full tour of the premises took place and the inspector saw most of the residents but was unable to speak with many due to their mental frailty. The inspector would like to thank the residents and staff at Surrey Heights for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? No requirements were made during the last inspection on 26th July 2005. The home has purchased some new furniture for the bedrooms and some decorating has taken place. Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 6 What they could do better: Eleven requirements have been made and can be seen n detail at the end of the report and these included: • • • • • • • • • • The local pharmacy policy to include details of their pharmacist and all staff that have left who previously administered medication to be identified on the staff signature sheet. The care plans to show the name the residents wish to be known as. The home to obtain a copy of the Multi Agency Policy on Abuse and for their local policy to be in line with Surrey. Routine maintenance to the property to be undertaken on a regular basis. Offensive odours to be eliminated. The staff rota to contain surname and designation. To provide CSCI with a copy of all training and the staff that has attended. To keep a record of valuables given to the home. Individual risk assessments for all areas of the home are completed. All exposed pipe-work to be covered and the electric heaters to be cooler or covered. The remaining Christmas lights that are still up now needs to be removed and the boxes put away that have been stored in the library. 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. Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Core standards covered at previous inspection and no concerns. Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 & 10 The medication was administered in the correct manner and records were accurately completed. There were no issues identified around privacy or dignity. EVIDENCE: All medication is kept in the manager’s office and the home has a medication policy. The inspector saw the home’s local policy but this did not contain details of their pharmacist so a requirement has been made at the end of the report. The inspector also noticed that the home has a list of signatures for all staff that administer the medication but there needs to be a leaving date added to the form so it is clear who the current staff are and this will also be a requirement at the end of the report. All staff administering medication receives training and are assessed by the manager. The staff is also qualified to NVQ level 3 No gaps were noted on the MAR sheet and the controlled drugs were checked and no errors found. The home has a privacy and dignity policy and when the G.P. visits residents are seen in private. The inspector could see no documentary evidence to show by which name the resident wished to be known as and this will be a Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 10 requirement at the end of the report. The inspector saw the staff knocking on the doors before entering and personnel care was being delivered appropriately. In the shared rooms portable screens are available in their rooms. Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 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 the following standard(s): 14 & 15 Resident’s are able to exercise control over their lives but this is limited due to their mental frailty. The dietary needs of the residents are well catered for with a balanced and varied menu. EVIDENCE: The residents at the home are mentally frail and although they are given choice about the meal they would like or where they would like to sit the senior carer told the inspector they could often forget. At lunch time there is a choice of two main meals and they can choose at the mealtime, which they would prefer. Personnel possession is bought into the home and the inspector saw these as she walked around and saw some bedrooms. No residents in the home are able to handle their own finances. The inspector was shown the menus. They work on a four-week cycle and the inspector saw both variety and choice. There are three main meals a day and also at 8pm the residents are offered a hot drink and sandwiches before bedtime. Fruit is offered during the afternoon and if they wish residents can have an early morning cup of tea. The inspector did not go to the kitchen and see the chef on this inspection as it was during the busy lunchtime period. Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 12 Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home needs to ensure that their own policy on abuse is in line with Surrey and that more training takes place for staff. EVIDENCE: The inspector found that the home had the Surrey Multi-Agency Procedures for adult protection but this was not the 2005 copy. The local policy for the home was available but this was not in line with Surrey therefore these will be requirements at the end of the report. The senior carer told the inspector that the training co-ordinator was sick at the time of inspection and complete training records were not available therefore it was not clear when adult protection training took place and who attended and this will also be a requirement at the end of the report for these records to be sent to the Commission to show when the training took place and who attended. Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home was clean and tidy but there was offensive odours noted on the middle floor. EVIDENCE: The inspector noted that the home was clean and tidy but that the middle floor had an offensive odour in one particular room, which affected the whole corridor. The senior carer was aware of the problem but said they had difficulty with this particular problem and the smell was always there. There will be a requirement at the end of the report. It was also noted that one particular bedroom had a wall in a shared room that was very dirty with smearing and the inspector requested that the home looks at this problem and notifies the Commission with an action plan for dealing with this. Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 The home has a good mix of staff on duty offering consistency in care and they are also qualified to do their job. EVIDENCE: The senior carer told the inspector that thee is always a level 3 NVQ trained carer on duty for all of the shifts. The inspector saw the rotas and noted that there always appeared to have adequate staff and the senior carer told the inspector that the home will adjust the number of staff according to the needs of the home and residents. The rotas only showed the first name and it will be a requirement at the end of the report to show surname and their qualification or job title. The home only has waking night staff. All staff at the home has NVQ level 2 or 3 and the deputy is in the process of studying for the level 4 qualification. All staff receives induction training, which takes part over five days and then linked to the foundation. The training coordinator is sick at the moment therefore the inspector would like confirmation from the home that induction is linked to the skills for care programme. All staff receive at least three days training during the year that includes dementia but the inspector would like to see a spreadsheet or training record to identify the training that has taken place and who attended. Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 35 & 38 A competent manager runs the home and residents financial interests are safeguarded. There are some health and safety and maintenance issues that need to be addressed. EVIDENCE: The registered Manager has completed her RMA and is also a registered nurse and registered mental nurse. She does some of the staff training and works closely with the training co-ordinator. It is the homes policy not to keep pocket money for the residents. Any items purchased will be invoiced monthly. Valuables will be locked away until the relatives can collect them. A permanent record needs to be kept of all things deposited and this will be a requirement at the end of the report. The homes have fire training twice a year and the alarms are tested weekly and recorded. The inspector looked at these records and noted that sometimes Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 17 there was a month between checks and this will be a requirement at the end of the report. The home has no risk assessments for individual areas and this will also be a requirement at the end of the report. Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 2 X X 2 Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement The registered persons to ensure that their local pharmacy policy contains details of their pharmacist. The registered persons to ensure that the list of staff signatures that the home uses for medication administration has a column to identify when a staff member leaves the home. The registered persons to ensure that the individual plans contain the name by which the residents prefer to be known as. The registered persons to ensure that they have the 2005 copy of the Surrey Multi Agency Policy and that their local abuse policy is in line with Surrey. The registered persons to ensure that routine maintenance to the property takes place on a regular basis and records are kept. The registered persons to ensure that offensive odours in the home are eliminated. The registered persons to ensure that the duty rota contains the surname and designation of staff DS0000013810.V266612.R01.S.doc Timescale for action 31/01/06 2 OP9 13 31/01/06 3 OP10 12 31/01/06 4 OP18 13 17/02/06 5 OP19 23 17/02/06 6 7 OP26 OP27 23 18 17/02/06 24/01/06 Surrey Heights Version 5.1 Page 20 8 OP30 18 9 OP35 16 10 OP38 13 11 OP38 13 The registered persons to ensure that CSCI is provided with a copy of all training that has taken place and who\ has taken part including evidence of mandatory training and protecting vulnerable adults. The registered persons to ensure that a permanent record is kept of any valuables given to the home for safe storage. The registered persons to ensure that individual risk assessments are completed for all areas of the home. The registered persons to ensure that all exposed pipe-work accessible to the residents is covered and the electric heaters surface temperatures are made safe. 17/02/06 17/02/06 17/03/06 17/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Surrey Heights DS0000013810.V266612.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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