Inspection on 17/10/06 for Surrey Heights

This inspection was carried out on 17th October 2006.

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 10/10/07

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 Lesley Garrett Unannounced Inspection 17th October 2006 09:00 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.V316294.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.V316294.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 g.john@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.V316294.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 January 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 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. The range of fees for the rooms are from £460 - £630 Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was held over six hours and commenced at 0930 and ending at 1530. Lesley Garrett lead inspector for the service carried out the site visit and the registered manager represented the establishment. The inspector carried out a tour of the premises and spoke with some service users and staff. Some policies and procedures, care plans and employment records for staff were sampled. A pre-inspection questionnaire and ‘comment cards’ provided by CSCI will also assist the inspection process. The inspector would like to thank the service users, staff and manager of the home for their hospitality during this site visit. What the service does well: What has improved since the last inspection? All requirements from the previous inspection have now been met. A programme of decoration has taken place and the upstairs corridors have been painted which now makes them cleaner and brighter. Communal armchairs and carpets have been replaced along with the dining room tables and chairs. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 6 One of the upstairs bathrooms has also been converted to a wet room making showering much easier for service users. 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. The summary of this inspection report can be made available in other formats on request. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 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.V316294.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users that move into the home have their needs assessed by someone competent to do so and are then assured that their needs would be met. The home has no intermediate care beds. EVIDENCE: The manager told the inspector that she would carry out all pre-admission assessments prior to service users moving into the home. If she is unavailable another suitably competent registered nurse will go in her place. The assessment tool used is comprehensive and the inspector sampled some of the assessments in the service users individual plans of care. The inspector also observed that care plans are then generated from this assessment. The home does not provide intermediate care beds. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 9 Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users individual plans of care are comprehensive and demonstrate that their health and personal care needs are met. The home has policies and procedures in place for the safe handling of medications and no issues around privacy and dignity were raised. EVIDENCE: The inspector sampled some individual plans of care and the manager explained the system that was used at the home. The manager stated that the home had simplified the documentation to ensure that the staff would ensure that they are completed and reviewed regularly. The inspector saw that all plans had been reviewed regularly and risk assessments were also in place. The manager said that the general practitioner (G.P.) visits the home every week and will come in between if necessary and is a good support to the home. The district nurse is also a regular visitor and on the day of the site visit she had come to do the routine blood samples. The home also has the support of the visiting opticians, chiropodist, dentist and physiotherapist. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 11 The inspector saw a copy of the homes privacy and dignity policy and the manager stated that this topic is also covered in the homes induction for all new staff. The inspector observed staff knocking on the bedroom doors prior to entering and all service users are addressed by their preferred name and this is documented. The manager stated that all service users would be seen in private by visiting professionals. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 12 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 available evidence including a visit to this service. Arrangements for meeting service users social needs were a good standard and visitors are made welcome to the home at all times. Service users were able to exercise choice and control over their lives as much as they are able. Visitors were made welcome by staff. The presentation of food and arrangements for provision of meals was to a good standard. EVIDENCE: The inspector met with the activities co-ordinator who works three days a week supported by another person who works two afternoons a week and one day. A programme of activities is drawn up in consultation with service users and their preferences. The range of activities varies and includes arts and crafts, crosswords and puzzles and some word games. On the day of the site visit the inspector observed some service users painting in preparation for Halloween. The activities co-ordinator told the inspector that a pianist visits every other week and service users really enjoy listening to the music and they Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 13 also enjoys the weekly exercise class. An activity is available every day of the week if service users wish to participate. Relatives and friends are welcomed to the home at any time and can also join in any activity. Pupils from a local senior school visit every week to talk to service users or to read newspapers. A church service is also held every month. The manager told the inspector that service users could have choice and control over their lives and staff assists them to do this. They choose where to eat their meals, and at a recent service user meeting they were shown the proposed winter menus. Service users selected the menus they would like and this has now been incorporated into the menu by the chef. The inspector met the chef who told her that he works full time supported by a part time chef. The home has had an environmental health visit recently and has now purchased a new fridge and freezer following their recommendation. Service users are given choice each day about what they would like to eat and that every Friday the service users can have a cooked breakfast. Fridge and freezer temperatures are taken and recorded which the inspector saw and all food stored in the fridge was labelled and dated. The inspector was told that there are two sittings for lunch to allow staff to give extra support to those service users who need it. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 14 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. Service users can be confident that their complaints will be listened to and taken seriously. Service users are protected from abuse. EVIDENCE: The home has a complaints policy which the inspector sampled this is available to every service user and is also displayed in the reception. The manager, to show the nature of the complaint and the investigations that take place and the outcome of the complaint, keeps a complaints log. The manager told the inspector that she had received two complaints this year which are now resolved. The inspector sampled the complaints received by the home and they had been investigated and resolved within the stated timescales. Service users at the home are protected from abuse. The inspector sampled the home’s safeguarding adult’s policy, which was in line with Surrey Multi Agency Procedures. The manager had a good knowledge of the procedures and told the inspector that she has had training on this subject and this is ongoing training for all staff. There has been one local authority referral this year, which has now been resolved. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 15 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and well-maintained environment, which is clean with no offensive odours. EVIDENCE: The inspector took a full tour of the home and found that since the last inspection the upstairs corridors had been decorated and this has made them much brighter and not so dull. The upstairs bathroom had been converted to a wet room but as the room is so large the home was able to keep the bath in there also. New armchairs and carpets for the communal areas have also been purchased and the dining room tables and chairs have been replaced. The home has a maintenance person who is responsible for all routine checks for example fire alarm testing and water temperature checks. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 16 The gardens are safe and accessible for service users with patio doors that lead out onto a decked area. The manager said this is used frequently on warmer days. The home was found to be clean and tidy with no offensive odours. The inspector met the cleaner who is also responsible for the laundry in the afternoons. He told the inspector about the routines in the laundry and had a good knowledge of infection control procedures and told the inspector that training has been given on this subject. The laundry is cleaned every day at the end of the shift and for such a little space it was found to be clean and tidy. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the numbers and skill mix of staff ensuring they are in safe hands at all times. The home has a good recruitment policy and practice to ensure service users are protected. There is regular training available for all grades of staff to ensure they are competent to do their jobs. EVIDENCE: The inspector saw the staff rotas on the day of inspection and found that the home had adequate staff on duty for the assessed needs of the service users. The manager said that staff could be increased if the dependency levels increase. Night staff at the home is awake and random checks are made to ensure that this happens. The manager told the inspector that all staff except for one has the level 3 national vocational qualification and this training is always on going in the home. The inspector sampled some staff employment folders and found that all documentation was in place, which protects the service users. Two references had been obtained and no staff was employed unless they had a satisfactory criminal records bureau check. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 18 The manager told the inspector that the company has a training co-ordinator who the inspector briefly met. She told the inspector that she develops a training plan for the home, which incorporates mandatory training for example safeguarding adults, fire awareness, manual handling and resuscitation. Individual records of participation are kept on the staff folders. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 19 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 available evidence including a visit to this service. Service users live in a home that is managed by an experienced person who discharges her responsibilities fully. There are good quality audits in place and the service users views are sought. Financial interests of service users are safeguarded and their health and safety is promoted and protected. EVIDENCE: The manager told the inspector that since the last inspection she has completed her registered managers award. She also has a postgraduate qualification in back care and the train the trainer’s award. There are clear lines of accountability within the home and the company and the manager’s operations manager is always available for advice. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 20 The manager stated that audits are regularly completed by the home and the inspector saw evidence of this. The inspector was told that any problems that are highlighted are then acted upon. Due to the mental frailty of the service users it is not possible to always seek their views therefore the manager has devised a quality tool to assess their well being that the staff can use. Service user and relative meetings are held every three months and the manager told the inspector that she attends for the first part and then leaves. Minutes are taken by a nominated person and made available to all. This is done to allow them all to speak freely. The home does not hold money for the service users but valuables can be deposited safely until a relative or representative is able to collect them. The inspector had the assistance of the pre-inspection questionnaire to look at health and safety checks that has taken place for example this year the fire equipment, central heating, the lift and personal appliance test had all taken place. The inspector saw that the fire extinguishers had also been checked this year and was dated correctly. Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 21 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 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 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.V316294.R01.S.doc Version 5.2 Page 22 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. 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. Refer to Standard Good Practice Recommendations Surrey Heights DS0000013810.V316294.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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.V316294.R01.S.doc Version 5.2 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!