Inspection on 13/02/07 for Surrey Hills Nursing Home

This inspection was carried out on 13th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Surrey Hills Nursing Home 14/01/08

Surrey Hills Nursing Home 13/12/05

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 Mavis Clahar Unannounced Inspection 13th February 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Surrey Hills Nursing Home DS0000017646.V327690.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 Hills Nursing Home DS0000017646.V327690.R01.S.doc Version 5.2 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.V327690.R01.S.doc Version 5.2 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. 16th November 2006 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. There are twenty-nine single bedrooms, two of which have full en-suite facilities, and eight double bedrooms. There are a number of bathrooms and toilets situated on each floor. Nursing care is provided on two floors served by passenger lift and stairs 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. Fees at this home are in the range of £685 to £725 per week. Surrey Hills Nursing Home DS0000017646.V327690.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, which forms part of the homes first key inspection to be undertaken by the Commission for Social Care Inspection (CSCI) was undertaken by Mrs Mavis Clahar on the 13th February 2007 and lasted for six hours; commencing at 09:30 hours and concluding at 15:30. The majority of the service users were unable to express their thoughts and feelings about the care they receive due to their mental Health needs therefore, the information contained in this report was gathered mainly from observation by the inspector, speaking with one visitor to the home, speaking with three service users, speaking with care staff, information gathered from records kept at the home; and from the pre inspection questionnaires sent to CSCI by relatives The first part of the inspection was spent observing the registered nurse administering medication to service users. This was followed by time spent discussing the inspection process with the manager, followed by a tour of the home which included time spent in discussion with service users, care workers and the Chef. The manager and staff are aware of the Laws regarding equality and diversity and this was reflected in the staff mix. All service users in this home are Caucasian. CSCI received a number of completed questionnaires from relatives and professionals visiting the home and they all commented on the high standard of care their relatives receive at the home. All records sampled were up to date with care plans being signed by the service users or by relatives. One requirement regarding provision of suitable dividing screens for service users sharing a bedroom was issued on this visit. At present the home is undergoing major refurbishment and development primarily as a result of the requirements issued on the last inspection The inspector would like to thank all the service users, care staff and chef who made the visit so productive and pleasant on the day. Thanks also to all the relatives who took time to complete the Commission for Social Care Inspection (CSCI) questionnaire your views on the home are highly valued. What the service does well: Surrey Hills Nursing Home DS0000017646.V327690.R01.S.doc Version 5.2 Page 6 The home has endeavoured to comply with the requirements made on the last inspection. Observations of care staff interactions with service users indicated that service users were treated with dignity and respect. It was also observed that great care was taken in respect of the service users personal belongings and standards of cleanliness in bedrooms ensured service users lived in a safe, well-maintained environment. The home has a stable work force, which should benefit the service users. The home has made suitable arrangements to maintain service users safety whilst the home is undergoing major refurbishment and redecorating 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. The summary of this inspection report can be made available in other formats on request. Surrey Hills Nursing Home DS0000017646.V327690.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 Hills Nursing Home DS0000017646.V327690.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): 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have the information needed to make a choice about whether the home will meet their needs. EVIDENCE: The home has a policy and procedure on admission and discharge of service users. Within the admission policy all service users must have an assessment prior to being admitted into the home. The manager who is trained in the principles of assessment of service users’ care and health needs carries out all pre admission assessments. Review of a random sample of service user’s files demonstrated that pre admission assessments are being carried out. Standard 6 does not apply to this home. Surrey Hills Nursing Home DS0000017646.V327690.R01.S.doc Version 5.2 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. 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 home has a good and clear care plan in place for service users, which also includes appropriate risks assessments. This forms the basis for care based on the agreed care needs of the service users and demonstrated that health and personal care needs were met. Care staff receives training to meet the assessed care needs of the service users ensuring that competent staff supports service users and their health and care needs are met. The home’s medication policy on receiving, storing and administering and return of medication was in place and being adhered to thereby ensuring the safety and protection of the service users. Care workers were observed treating service users with respect and to maintain their dignity and privacy when delivering personal care. Surrey Hills Nursing Home DS0000017646.V327690.R01.S.doc Version 5.2 Page 10 EVIDENCE: The randomly selected care plans were clear and easy to read, identifying potential and actual risks to service users. The daily work sheet along with discussion with service users demonstrated that service users care needs are fully met. No service user at the time of inspection was assessed as capable to selfadminister their medication, but the manager was knowledgeable about what to do should this situation arise. Good clear records are kept of medication receipts, storage, administration and returns. Care staff identified as capable to administer medication are requested to leave a specimen of their signature in the medication trolley. All service users have a recent photograph included in their medication record to reduce the risk of mistakes happening during medication administration. There was one visitor to the home who spoke with the inspector. This relative was happy with the care given to the relative. He said the staff are always polite to him and he was free to visit any part of the home his relative was using. Relatives’ responses to the CSCI pre inspection questionnaires were very positive. One relative wrote “ I am satisfied with the care my relative receives at this home”. Service users were observed being treated in a friendly but respectful manner by care workers. Surrey Hills Nursing Home DS0000017646.V327690.R01.S.doc Version 5.2 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. 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. Service users lifestyles matched their needs and preferences and where possible they are able to maintain contact with family, friends and the local community. Service users are able to make choices in accordance with their abilities and were provided with a balanced diet in pleasant surroundings and in an unhurried way. EVIDENCE: The home employs an activity-co-ordinator who provides a range of activities based on the needs of the service users. This activity can be one to one as observed on the day of the inspection or in a group. It was noted that care workers were also involved in the exercises with their service users Surrey Hills Nursing Home DS0000017646.V327690.R01.S.doc Version 5.2 Page 12 Visiting is open, and service users can entertain their guests in their bedrooms in private or in the spacious communal areas of the home. The Church of England Vicar visits on a regular basis. Three of the service users spoken to said they had choice in their clothing. Sometimes they receive help from their key worker. On the day of inspection all service users were dressed appropriately for the cold weather. The inspector did not sample the food but service users spoken to say the food was very good and plentiful and they can have more if they wish. The inspector noted that some meals were liquidised and in discussion with the Chef, she informed the inspector that fourteen service users need liquidised diets and that she tries to add some thing exciting to the liquidised meals each time. Today she added cream to the white sauce, which she used to liquidise the gammon. The Chef operates from a four-week menu with the winter menu being in use now. There is always a choice of two hot meals per day at midday, or salad at mid-day or the service user can choose their own food such as omelettes. On the day of inspection service users had a choice of three main dishes, followed by dessert. The inspector observed care workers helping service users with their meal, sitting and speaking with service users in a friendly and encouraging way. One visitor was also sat with their relative helping and encouraging the relative to eat their meal. Surrey Hills Nursing Home DS0000017646.V327690.R01.S.doc Version 5.2 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. 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. The home has a satisfactory complaints policy and procedure and training in place that evidenced that service users and relatives concerns are listened to and acted upon. Robust Safeguarding adults’ policies are in place to protect the service users from abuse. EVIDENCE: CSCI Eashing received no complaints about the home. Four substantiated complaints regarding laundry were logged at the home, and were all dealt with satisfactorily according to the home’s records; and within the home’s time scale for dealing with complaints. The manager informed the inspector that she is in touch with service users on a daily basis and issues raised are dealt with immediately; this reduces the incidents of formal complaints. Service users and relative spoken to said they have no need to complain, as they are able to discuss everything with the manager. The home has a complaints procedure and policy, which is fully adhered to. The care workers were aware of the homes’ policy and procedure on Safeguarding Adults and felt secure in the knowledge that if they had to use Surrey Hills Nursing Home DS0000017646.V327690.R01.S.doc Version 5.2 Page 14 the whistle blowing procedure the manager and the Owners of the company would support them. A random sample of care workers training record demonstrated that care workers are being trained to undertake the duties of meeting the service users assessed needs, thereby protecting them from abuse. Surrey Hills Nursing Home DS0000017646.V327690.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 24 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables service users to live in a safe, and comfortable environment, which encourages independence. However, the home is undergoing their rolling programme of improvements, and part of the home has been cordoned off from service users whilst this work is being undertaken. EVIDENCE: At the last inspection visit, a number of requirements were issued regarding the upkeep and maintenance of the home. Currently the home is undergoing vast remodelling and improvements. Although the workmen were present on the day of the visit, service users were observed to be not in any danger from the work being carried out as health and safety precautions were in place to protect the service users. In discussion with one service user, they said they Surrey Hills Nursing Home DS0000017646.V327690.R01.S.doc Version 5.2 Page 16 were pleased to have the workmen around, as the home will look very nice when they are finished. They further said having the workmen at the home was not a problem as the areas they are working on is boarded off. It was noted that care staff had training in infection control as logged in their training files. It was noted in two shared bedrooms that the screens provided did not ensure service users privacy when undertaking personal care. A requirement was issued on this standard. Generally the home presents as clean, pleasant with no detected mal odours present. Surrey Hills Nursing Home DS0000017646.V327690.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): 27 28 29 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of the service users. Staff are appropriately supervised and recruitment practice ensures the protection of service users. EVIDENCE: The staff rota demonstrated the number and grade of staff on duty to provide care and attention to service users for any twenty-four hour period was adequate to meet the assessed care needs of the service users. The home has a programme of planned training in place and all members of staff have an individual training record. Over 50 of care workers have attained the National VocationQualification at Level 2 (NVQ L2). Care workers are encouraged and enabled to undertake developmental training as well as the mandatory training. . All newly appointed staff undertakes an induction programme. The home ensures that staff undertakes the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the manager and care workers and from review of care workers training records. Surrey Hills Nursing Home DS0000017646.V327690.R01.S.doc Version 5.2 Page 18 It was noted that staff turnover at the home is relatively low. All care workers are Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checked prior to commencing employment, and they are in receipt of terms and conditions of employment as evidenced in their randomly selected files. The manager informed the inspector that supervision record were up to date and this was verified during random sampling of care workers files. The manager had shown the inspector her planned programme of improvements and supervision of staff was high on her agenda Surrey Hills Nursing Home DS0000017646.V327690.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. The manager has the experience to run the home and works to continuously improve services and provide an increased quality of life for the service users. There is a strong ethos of being transparent and open in all areas of running the home and service users’ relatives are involved. The views of service users relatives are actively sought in the running of the home and service users financial interests are safeguarded. The health, safety and welfare of service users is promoted and protected. EVIDENCE: Surrey Hills Nursing Home DS0000017646.V327690.R01.S.doc Version 5.2 Page 20 The manager has demonstrated that she has kept herself updated on issues relating to care of the service users and staff in her charge. She has attained the Registered Managers Award and also the National Vocational Qualification Level 4 in care. She is currently undertaking the Gold Standards Framework course in conjunction with other multi-disciplinary professional team members. In discussion with the manager it was evident she was knowledgeable about the care needs of the service users and the training needs of the care workers to meet these identified needs. There are clear lines of accountability within the home, each member of staff spoken to on the day of inspection aware of their role and responsibilities. The majority of the service users in this home are unable to participate in the running of the home. However, the manager informed the inspector that relatives’ involvement is encouraged. The one visitor who spoke with the inspector supported this. It was reported that only three service users are capable of providing verbal feedback and one confirmed their relative’s involvement. The manager said she has sent out the Relatives Quality Audit and is currently awaiting their return, when they will be analysed and distributed in the general newsletter. The home does not become involved in service user’s finance. The relatives/court manages all service users’ finance. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. There was evidence that all equipment examined on the day was properly maintained. Records indicated that fire drills, fire alarm, water temperature fridge and freezer recordings were regularly checked. Random sample of care workers’ training files demonstrated that up to date and relevant training were carried out by care workers to protect service users’ health, welfare and safety. In discussion with care workers they spoke about their understanding and implementation of appropriate procedures to safeguard service users. Furthermore they spoke about their understanding of promoting safe working practices based on their health and safety training. Throughout the service there is a highly evolved understanding of the equality and diversity needs of the individual service users. Care workers are confident in delivering high quality outcomes for service users in the areas of age, sexuality, gender, disability and belief. Although the care workers are knowledgeable about issues relating to race and equality and diversity, they are not able at the moment to put this knowledge into practice, as the current service users are all Caucasians. Surrey Hills Nursing Home DS0000017646.V327690.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 N/A 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 2 X X X X 2 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 Hills Nursing Home DS0000017646.V327690.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. 1 Standard OP24 Regulation 16 (2) © Requirement Curtains used, as screens in bedrooms 44 and 46 must be long and wide enough to ensure service users privacy is not compromised when undertaking personal care. Timescale for action 13/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Surrey Hills Nursing Home DS0000017646.V327690.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 Hills Nursing Home DS0000017646.V327690.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. 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