Inspection on 16/06/05 for Sydenhurst

This inspection was carried out on 16th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sydenhurst 26/06/09

Sydenhurst 25/06/07

Sydenhurst 26/09/05

Sydenhurst 20/01/05

Sydenhurst 23/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Sydenhurst Mill Lane Chiddingfold Surrey GU8 4SJ Lead Inspector Miss Marianne Barham Announced 16 June 2005 th 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. Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sydenhurst Address Mill Lane Chiddingfold Surrey GU8 4SJ 01248 683124 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) Association of Ukrainians in Great Britain David James White Care Home 32 Category(ies) of DE(E) - Dementia over 65 (16) registration, with number of places MD - Mental Dissorder (1) OP - Old Age (14) PD(E) - Physical Disability over 65 (4) Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only 1 (one) named service user in the category MD over the age of 60 years. 2. Of the older people (OP) accomodated, up to 4 (four) may be in the category PD(E) 3. Additional staff be allocated based upon the figures supplied by the residential forum 4. The statement of purpose and service users guide are required to be amended to include the change within the capacity of the home. Date of last inspection 20th January 2005 Brief Description of the Service: Sydenhurst is a large detached property set in its own enclosed grounds and located in the village of Chiddingfold. It is owned and managed by The Association of Ukrainians in Great Britain and provides care and accommodation to up to thirty-two older people, some of whom may also have a physical disability and/or dementia. The accommodation is arranged over three floors and has a number of communal sitting rooms, a spacious dining room and a large kitchen located on the ground floor. There is an adapted shower room on the ground floor and adapted bathrooms on the ground and first floor, with a standard bathroom on the second floor. The first and second floor can be reached by staicase or passenger lift. There are 23 single bedrooms, 11 of which have en-suite facilities, and 4 twin bedrooms, 1 of which has en-suite facilities. Those rooms without en-suite have toilet and bathing facilities located nearby. The home has its own mini-bus and people carrier to access activities and amenities in the local community. Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out at 10.50am by Marianne Barham, regulation inspector, on behalf of Susan McBriarty, lead inspector for the service. The inspection was carried out over a period of five hours and was the first inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The registered manager Mr David White was present and a total of six service users, five members of staff and two visiting health professionals were spoken with during this inspection. Several comment cards from relatives and service users were received prior to the inspection and records relating to the care of service users and management of the home were examined. What the service does well: What has improved since the last inspection? All policies and procedures and service users contracts have been updated to reflect the change from National Care Standards Commission to CSCI, as required at the last inspection on 20th January 2005. Service users who need to use bed rails now have a risk assessment carried out and radiators now have covers fitted to them, improving the safety and welfare of service users. Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 Page 6 The home’s policy on protection of vulnerable adults has been reviewed and updated in line with the Surrey Multi-Agency Procedures and all staff members have now been referred to the Criminal records Bureau (CRB) for an enhanced disclosure and Protection of vulnerable Adults (POVA) check. 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. Sydenhurst H58_s13811_Sydenhurst_v223555_160605_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 Sydenhurst H58_s13811_Sydenhurst_v223555_160605_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) 1 and 2 Service users have enough information to make a choice about where they live and have a written contract with the home. EVIDENCE: The home has a clearly written Statement of Purpose and Service User Guide. These contain a wide range of information about the home and the services provided. Each service user is given a copy of the guide before admission to the home. The guide is available in 9 languages and also in large print and Braille. Each service user has a written contract stating the terms and conditions of residence at the home. These contracts are signed, either by the service user, or a representative. The home is currently updating the service user contracts to reflect the recent guidance from The Office of Fair Trading. The contracts now reflect the change from NCSC to CSCI, thus meeting a requirement made at the last inspection on 20th January 2005. Risk assessments are now in place for the use of bed rails, again meeting a requirement made at the last inspection. Sydenhurst H58_s13811_Sydenhurst_v223555_160605_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 Service users have a plan that identifies their health, personal and social care needs. EVIDENCE: A number of care plans were examined. These were clearly written and gave detailed information on the care needs of the service users. The plans are generated from the pre-admission assessment and take account of all areas of the persons needs, from physical needs through to emotional and social needs. Service users with specific needs such as diabetes or dementia have clear guidance for members of staff to follow in order to meet their needs. The plans are reviewed monthly and any changes noted. Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 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 standard(s) 12, 13 and 14 The lifestyle in the home reflects the social, cultural and religious needs of the service users, they are supported to make choices about their lives and they are able to maintain links with their family, friends and the local community. EVIDENCE: The home offers a wide range of activities to the service users. These include live singers twice a month, reminiscence sessions and visiting theatre groups. The local community is accessed fully by the service users and they are supported to attend clubs in the village and religious services. Records of activities undertaken are recorded in the care plan. Service users also attend a day centre and regularly have trips out to pubs, restaurants and places of interest. Service users spoken with stated that they enjoy the activities offered and were able to choose whether to take part. All confirmed that they were able to receive visitors in private and when they chose. The home also supports service users to maintain their cultural and religious identities through observations of traditional and religious festivals relevant to individual service users. Religious services from differing denominations are also held regularly in the home. Information on each person’s cultural and religious needs is recorded in the care plan. Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 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 standard(s) 16 and 18 Service users are protected from abuse and they, and their families can be sure that their complaints will be listened to and acted upon. EVIDENCE: The home has a complaints procedure in place and this is contained in the service users guide. The procedure gives clear and accurate information on the process of making a complaint. It has been updated to reflect the change from NCSC to CSCI, meeting a requirement made at the last inspection. A record of complaints is kept, along with actions taken to resolve them. The home has a policy and procedure on the protection of vulnerable adults that follows the guidance of the Surrey Multi-Agency Procedures. These procedures, reviewed in February 2005, are also maintained at the home. All staff members have received training on the protection of vulnerable adults and the home has a whistle-blowing policy that staff members are made aware of it at induction into the home. Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 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 standard(s) 19 and 26 Service users live in a safe, clean and comfortable home that is maintained to a good standard. EVIDENCE: The home is generally well maintained and decorated. It is very clean throughout and many areas of the home have undergone refurbishment recently. Records of servicing of equipment and repairs are kept and an ongoing programme of decoration, maintenance and repairs is in place. There is one room that is in a poor state of repair and cleanliness. This is due to the service user refusing to allow domestic staff to clean properly. This service user also smokes in this room. A risk assessment for this has now been carried out, meeting a requirement made at the last inspection. The manager stated that this room is under constant review and is due to be completely refurbished within two weeks of the date of this inspection and that Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 Page 13 relatives had given permission for washable floor covering to be laid to assist cleaning. This meets the requirement made at the last inspection. Service users spoken with were happy with the accommodation and felt that their rooms were comfortable and suited their needs. A requirement was made at the last inspection to install covers on radiators as part of the refurbishment process. This is being done, with only areas not yet refurbished not having radiator covers. A requirement was made at the last inspection to forward a copy of the electrical wiring certificate to the commission once the rewiring is completed. As the work is still in progress this cannot be done. This requirement has been carried forward. Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 Page 14 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) 27 and 30 The number and skill mix of the staff team meets the needs of service users and staff members are trained and competent to carry out their duties. EVIDENCE: The skill mix and levels of staff in the home exceed the recommendations of the residential forum. Rosters were examined and confirmed this. The manager is supernumerary apart from one day a week and there is always a senior staff member to lead shifts. The home employs maintenance, domestic and catering staff, enabling the care staff to concentrate on service users. Any shortfall of staff levels is covered by a bank system, agency workers are rarely used. The home has accommodation available for staff and this is a positive factor when recruiting new staff. The home is strongly committed to the training and development of the staff team and this reflected in their recent attainment of the Investors in People Award. The home has a comprehensive training programme in place that is put together from the training and development needs identified through staff appraisal. Staff spoken with during the inspection stated that they received regular supervision and support to carry out their duties and that they were able to access a wide variety of training courses. Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 Page 15 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) 35 and 38 The health, safety and welfare of service users are promoted and protected and their financial interests are safeguarded by the home. EVIDENCE: The home is not involved in service users finances any extra services are invoiced directly to the service user or their representative. Records of purchases and receipts are maintained. The home has a comprehensive policy and procedure in place for health and safety. The staff team are made aware of this at induction and through team meeting. The policies are reviewed and updated regularly. Risk assessments have been carried out for a wide range of work activities with clear guidelines in place for the management of identified risks. All staff members receive training on health and safety issues such as fire safety, infection control and moving and handling and there is a nominated member of staff who acts as a health and safety coordinator. Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 Page 16 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 3 3 x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x 3 3 Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 Page 17 YES 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 19 Regulation 13(3) (a) (c) Requirement The manager must ensure that a copy of the electrical safety certificate is forwarded to the commision as soon as the rewiring is completed. Timescale for action 16/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 Page 18 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. Extracts may not be used or reproduced without the express permission of CSCI Sydenhurst H58_s13811_Sydenhurst_v223555_160605_stage 4.doc Version 1.30 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. 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