Inspection on 26/07/05 for Surrey Heights

This inspection was carried out on 26th July 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

Surrey Heights 10/10/07

Surrey Heights 17/10/06

Surrey Heights 17/01/06

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 Brook Road Wormley Surrey GU8 5UA Lead Inspector Lesley Garrett Announced 26 July 2005 09:30 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. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Surrey Heights Address Brook Road Wormley Surrey GU8 5UA 01428 682734 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) Mr L K Hasham & Mrs N Hasham, Care Homes of Distinction, Head Office, Surrey Heights, Brook Road, Wormley, Godalming, Surrey, GU8 5UA Michele Woodger Care Home (CRH) 39 Category(ies) of Old age, not falling within any other category registration, with number (OP) 7 of places Dementia - over 65 years of age (DE(E)) 32 Sensory Impairment over 65 years of age (SI(E)) 4 Physical disability over 65 years of age (PD(E)) 2 Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 Stage 4.doc Version 1.30 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 Date of last inspection 14th July 2004 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 accomodation, 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 H58-H09 S13810 Surrey Heights V229306 260705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over four and a half hours and was the first 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 the inspection. Michele Woodger registered manager and Anna White, the administrator, represented the establishment. A tour of the premises took place. The inspector saw a number of residents and spoke with eight of them. Two staff was interviewed. A pre-inspection questionnaire and a number of returned comment cards were also used to compile this report. The service users will be referred to as residents as this is the familiar name in this home. This was a positive inspection. The inspector would like to thank the residents, staff and manager at Surrey Heights for their time, assistance and hospitality during this inspection. What the service does well: The manager is positive in her attitude to the residents and is keen to involve them in decisions as much as possible. She also has good communication with the relatives and representatives. There was evidence of good practice, which the inspector noted. The manager keeps a record of all accidents or incidents that happen in the home and produces a graph every quarter to compare results with the previous year. She then holds meetings with staff to identify the risks and to see if any can be eliminated or reduced. A detailed night care plan has just been introduced for each resident, which is kept in his or her individual files. This gives information for all the residents during that twelve-hour period. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 Stage 4.doc Version 1.30 Page 6 The manager has also put together a relative information folder, which contains information on advocacy, benefits and anything else that she feels they would wish to know. What has improved since the last inspection? 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. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 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 Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 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 The home has good pre-admission assessment documentation allowing the manager to make an informed decision about admission. EVIDENCE: The manager does all the pre-admission assessments prior to any admission to the home. She has developed a standard form to use and this incorporates the National Minimum Standards guidelines for pre-admission assessments. Any resident who is admitted through a care manager also has an assessment but there is also their assessment from which care plans will be formulated and there is also a health needs assessment. The inspector looked at the file of a recent admission to the home and this contained all the information stated above. The pre-admission assessment is kept in a separate file to the care plans but when the inspector checked the other file of this resident care plans were in place that matched the assessment. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 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 There is a clear care planning system and the health needs of the residents are well met with evidence of multi disciplinary working on a regular basis. EVIDENCE: The home operates a key worker system and they are responsible for regular reviews of all care plans and risk assessments. The individual resident files incorporate all the information gathered from the pre-admission assessment. The plans are reviewed on a monthly basis with the resident, if able to sign and understand, and also their relative or representative. The manager recognised that the residents who have a care manager are invited to a review every year along with their relative, key worker, and the manager. This did not happen for all residents and relatives so the manager invites the rest of the residents and relatives by letter to a formal review of their documentation also yearly. The home has support from the local G.P. who visits the home every week. While the inspector was there the district nurse was visiting to take some routine bloods and to check a couple of dressings. The district nurse visits Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 Stage 4.doc Version 1.30 Page 10 regularly and spoke with the manager before she left to hand over any relevant information. One particular resident required a pressure-relieving mattress, which the district nurse was organising. The home also has access to a dentist, a chiropodist who visits every six weeks and opticians who visit twice a year. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 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 The home has a plan of activities and there are links with the community to enrich their lives. EVIDENCE: The inspector spoke with an activity provider who visits the home once a week. The residents were busy colouring in posters for a forth-coming fete. The two residents that the inspector spoke to told her they were not very good at this but they hardly looked up and was concentrating hard on what they were doing. A carer, who has attended an activities course, prepares the daily programme of events. Most mornings are spent on grooming for example hair and manicures. The manager stated that a lot of the residents are up early and so activities in the morning are often suitable. Activities in the afternoon include reminiscing, singing, dancing, playing instruments exercise class and ball games. The home has its own minibus, which allows the residents to go out on trips. They have visited a local garden centre for afternoon tea and to the local pub for coffee or a drink. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 Stage 4.doc Version 1.30 Page 12 The local school visits once a week to do activities or to just sit and talk to the residents. The manager stated that the residents really enjoyed this time with the children. The vicar visits every month to hold communion. Visitors are welcome to the home when ever they want to come with no restrictions on visiting times. They can visit in private if they wish in their own rooms. The residents that wish have their own newspaper delivered to them. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 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 The home has a satisfactory complaints system and residents and relatives views are listened to and acted upon. EVIDENCE: The home has a complaints policy, which is displayed in the lounge. It is also contained in the service user guide. Relatives or representatives are also given a copy. The last complaint received by the home was in February this year. The manager had resolved it satisfactorily. The manager stated that there is a complaints record folder and either herself or the administrator will complete the paperwork. The complaints procedure also contains the address and telephone number of CSCI. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 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 The recent refurbishments have improved the appearance of the home creating a safe and comfortable environment for those living there. EVIDENCE: The inspector was shown a maintenance programme for the home. The home also keeps a maintenance book where any problems are logged and then signed for when the job is done. The manager stated that the home has a two maintenance men one works every Friday and the other two and a half days a week. Any large maintenance problems will be given to contractors and there is a list in the office of who to contact in an emergency. The home has a gardener who comes on a Monday to mow the lawns and tend to the flowerbeds. There is a large garden, which has a large drop at the back of the conservatory. The manager stated and showed the inspector that the residents can only access the garden by the side door and are always accompanied when going into the garden. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 Stage 4.doc Version 1.30 Page 15 Environmental health had done their inspection in March 2005 and the only recommendation was for the manager to complete a hazard analysis. This has now been completed and returned to them for comments. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 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) 29 The residents are protected by the homes recruitment practices. EVIDENCE: The inspector looked at two recruitment files and spoke with both carers. The files contained an application form, contract, two references and CRB checks. The inspector spoke with both members of staff one had been employed for seven years and the other was a new recruit in the last seven months. There was evidence in their files of good recruitment practice with all documentation in place. Also contained in the files were certificates from the various training courses they had attended. The longest serving member of staff was level 2 and 3 NVQ trained and the newest member had completed her TOPPS induction course. The manager stated all staffs CRB checks are kept separately from the file and they are kept securely in a locked cupboard. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 Stage 4.doc Version 1.30 Page 17 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 The system for resident consultation is good with a variety of evidence that indicates resident’s views are sought and acted upon. EVIDENCE: The manager stated that she did organise a variety of consultations and audits. The resident’s mental frailty meant that they were not all able to complete questionnaires themselves so she involves the families also. Another way of auditing is observing and the manager also uses this method. At the end of every year the manager organises a residents survey and in the middle of the year she does a survey for the relatives or representatives to complete. The manager stated these surveys are used to change practice. One example of this is that one survey showed a particular problem with hairdressing and therefore it was changed. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 Stage 4.doc Version 1.30 Page 18 The manager also organises medication, mattress and care plan audits. There is also observing audits where members of staff will observe a particular activity to see what actually happens and then implement changes if necessary. The home also has relative meetings and they decide the agenda and minutes are kept of these meetings. There is also a quarterly newsletter. Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 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 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 x x x x x Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 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 Surrey Heights H58-H09 S13810 Surrey Heights V229306 260705 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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