Inspection on 13/12/05 for Surrey Hills Nursing Home

This inspection was carried out on 13th December 2005.

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 Hills Nursing Home 14/01/08

Surrey Hills Nursing Home 13/02/07

Surrey Hills Nursing Home 23/08/04

Surrey Hills Nursing Home 21/05/04

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

CARE HOMES FOR OLDER PEOPLE Surrey Hills Nursing Home Brook Road Wormley Godalming Surrey GU8 5UA Lead Inspector Lesley Garrett Unannounced Inspection 13th December 2005 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 Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 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 Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Surrey Hills Nursing Home Address Brook Road Wormley Godalming Surrey GU8 5UA 01428 682346 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) G.JOHNATCAREHOMESOFDISTINCTION.CO.UK Mr L Hasham Mrs N Hasham Mrs Patricia A Grimwood Care Home 45 Category(ies) of Dementia - over 65 years of age (45) registration, with number of places Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. In respect of this home, service users may be admitted from the age of 60 YEARS. Accommodation may be provided for one (1) named service user under the age of 60 years. 4th July 2005 Date of last inspection Brief Description of the Service: Surrey Hills is a registered care home, one of a group of similar services run by Care Homes of Distinction, in the area. The home is a large detached premises situated in the village of Wormley, in picturesque Surrey countryside. Nursing care is provided for forty-five older service users with dementia. There are road and train links to the village and the home provides car-parking facilities. Catering is in-house. There is a staff team with nurses and carers who are supported by a wider network of health care professionals offering holistic care. . Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 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 Patricia Grimwood Registered Manager represented the establishment. A full tour of the premises took place and the inspector looked at recruitment files, medication documentation and some policies and procedures. The inspector saw most of the residents but was unable to speak with many due to their mental frailty. There was a relative visiting who told the inspector that ‘they look after my brother very well’. The inspector would like to thank the residents, staff and manager at Surrey Hills 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 at the last inspection. There have been no changes since the last inspection Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 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 Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 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 seen at the last inspection 4th July 2005 Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 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 system for administration of medicines is adequate. The resident’s right to privacy is upheld. EVIDENCE: The inspector looked at the medication system and found the home has a medication policy but there is no local policy that is relevant to their home. The home uses a local pharmacy and the medication is delivered monthly in blister packs. The controlled drugs are checked at every handover morning and evening and the inspector sampled one resident’s and found it to be correct. All rooms have locks and shared rooms have curtains to maintain privacy during personal care. The doctor can see the resident’s in their own room or there is a clinical room with a couch and can see them in there if they are not too ill. The home has a privacy and dignity policy. Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 10 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 Resident’s are able to exercise some control over their lives. EVIDENCE: The manager stated that residents are able to exercise control over their lives but due to their mental frailty they will often forget. During the inspection the inspector saw some resident’s in bed because they had chosen to get up later. The manager stated that some really enjoy their bed and therefore do not request to get up early. The resident’s choose which clothes they will wear that day and will sometimes select clothes that are inappropriate for the weather as evidenced in the resident survey a relative stated that a particular resident had selected a thick woolly jumper in the summer. They all have a choice of menu and this is chosen on the day otherwise they will forget what they have ordered. The inspector saw personnel possessions in the room and their doors had photographs to help them identify it. Mainly family and friends act on their behalf and some have a solicitor as power of attorney. Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 11 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): 16 The home has an adequate complaints system in place and they have few complaints. EVIDENCE: The manager stated that since the last inspection she had received only one complaint which had been investigated and was now resolved. The complaints policy is available for all residents and is displayed in the reception. Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 12 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): 19 The home now needs decorating as the paintwork and general decoration is of a poor standard and there is no evidence of regular maintenance taking place. EVIDENCE: As the inspector walked around the home it was noted that several of the rooms and all the corridors and communal areas now need decorating. A requirement has been made at the end of the report for the registered persons to look at all areas of the home and supply CSCI with an action plan detailing timescales for this refurbishment programme. The laundry room also needs refurbishment as the wall finishes are not easily cleanable and a new floor is required. The sink is also very stained and dirty. The veranda also needs to be cleared of the old furniture and the bar-b-q to allow access for any residents that may wish to use this facility. The lighting in the corridors and some bedrooms is inadequate and this also needs to be reviewed. The inspector also noted that hot water was coming from al hand basins and this is also a requirement to fit thermostatic valves. Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 13 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): 29 Recruitment practices are adequate but there was some gaps noted. EVIDENCE: The inspector checked some recruitment files and noted that all files checked had something missing. To ensure good practice it has been made a requirement at the end of the report that the registered persons look at all files to ensure they comply with current legislation. Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 14 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): 33 35 & 38 The manager has done regular surveys for the residents. It is the homes policy not to keep pocket money accounts. Most health and safety checks have been complied with. EVIDENCE: The manager stated that twice a year surveys are sent to the residents to complete for quality assurance. Due to the mental frailty relatives are also given the surveys to complete. The manager then acts upon the comments and actions those that are necessary. During a recent management meeting the managers have been told to now do these surveys quarterly. It is the homes policy not to keep pocket money accounts. The home does have a safe and anything deposited is listed and then signed for when the items are collected. Health and safety practices are generally good. A pre-inspection questionnaire was completed for the inspection in July6 that the inspector checked. Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 15 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 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 1 X X X X X 1 X STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 16 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 (2) Requirement The registered persons to ensure that all resident’s have a photograph to enable the safe administration of medicines. The registered persons to write a local medication policy and procedure. The registered persons to ensure that the laundry room is refurbished. The registered persons must look at and assess all bedrooms, corridors and communal areas to be re-decorated and made good and supply CSCI with an action plan within a reasonable timescale to complete the work. The registered persons to remove the furniture and generally tidy the veranda. The registered persons to ensure that the light switch in the dining room is repaired. The registered persons to look at room 27 and to consider changing this to a single room to enable the resident’s to have all the equipment they may need. The registered persons to ensure DS0000017646.V266615.R01.S.doc Timescale for action 27/12/05 2 3 4 OP9 OP26OP19 OP19 13(2) 23(2)(d) 23(2)(d) 13/01/06 13/03/06 13/01/06 5 6 7 OP19 OP19 OP23 23(2)(o) 23(2)(b) 16(2)(c) 20/12/05 20/12/05 13/01/06 8 OP25 12(1)(a) 13/01/06 Page 17 Surrey Hills Nursing Home Version 5.0 9 OP25 23(2)(p) 10 11 12 OP26 OP29 OP37 16(2)(k) 19(1)(b)& schedule 2 12(4)(a) that thermostatic valves are fitted to all hand basins. The registered persons to improve the quality of the lighting in the corridors and some bedrooms. The registered persons to eliminate the offensive odours in rooms 18 and 41. The registered persons to ensure that all recruitment files have the necessary documentation. The registered persons to remove documentation that is on the walls in the dining room and refers to certain residents in order to maintain their privacy. 31/03/06 13/01/06 13/01/06 20/12/05 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 Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 18 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. Extracts may not be used or reproduced without the express permission of CSCI Surrey Hills Nursing Home DS0000017646.V266615.R01.S.doc Version 5.0 Page 19 - 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!