Inspection on 26/09/05 for Sydenhurst

This inspection was carried out on 26th September 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

Sydenhurst 26/06/09

Sydenhurst 25/06/07

Sydenhurst 16/06/05

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 Sydenhurst Mill Lane Chiddingfold Surrey GU8 4SJ Lead Inspector Susan McBriarty Unannounced Inspection 26th September 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 Sydenhurst DS0000013811.V253510.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. Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sydenhurst Address Sydenhurst Mill Lane Chiddingfold Surrey GU8 4SJ 01428 683124 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) Association of Ukrainians in Great Britain David James White Care Home 32 Category(ies) of Dementia - over 65 years of age (16), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (14), Physical disability over 65 years of age (4) Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Only 1 (one) named Service User in the category MD over the age of 60 years. Of the older people (OP) accomodated, up to 4 (four) may be in the category PD(E). Additional staff be allocated based upon the figures supplied by the Residential Forum. The Statement of purpose and Service Users Guide are required to be amended to include the change within the capacity of the home. 16th June 2005 Date of last inspection 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 DS0000013811.V253510.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection the second for 2005 – 2006. Previous inspection reports are available on request from the Commission for Social Care Inspection. During the inspection the Inspector spoke with three staff excluding the manager and three residents. A number of the residents have dementia and were not able to speak to the Inspector, some chose not to and others made only short comments when spoken with. A number of documents were sampled during the inspection including; staff personnel files, residents admission files, medication administration records, a number policies and procedures and staff training information. A tour of the communal spaces, some bedrooms and the immediate grounds took place. Menus were seen and residents were observed during the lunch period, the food was not sampled during the inspection. What the service does well: What has improved since the last inspection? What they could do better: During the inspection a requirement was made for the home to review the procedures for the administration of medication, a number of gaps were found in the medication administration record. The home has provided a separate area on the ground floor for those residents with dementia. The door into this unit does not have a safety device fitted to Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 Page 6 reduce the risk of residents leaving the area. The manager informed the Inspector a safety device was being considered. It is recommended that the home follow through their plan to provide such a safety devise. A quality assurance audit had taken place, however the manager was unable to locate a copy of the outcome. A requirement was made that a copy be forwarded to the Commission for Social Care Inspection for information. 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 DS0000013811.V253510.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 Sydenhurst DS0000013811.V253510.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): 3,4,5 Standard 6 is not applicable. Prospective residents are assessed prior to admission and trial visits are encouraged. The provides services for residents from a specific ethnic minority group. EVIDENCE: The Inspector sampled a number of resident files containing basic personal information. The files viewed held copies of pre-admission assessments, contracts signed by the residents and a short history of the specified person. The home has an admission criteria policy informing staff of the assessed needs the home is able to meet. In addition a policy and procedure is in place regarding trial visits. The manager informed the Inspector that one resident who has recently moved in spent two days at the home before deciding whether to move in. The home is able to meet the needs of those from the Ukraine including language, social and cultural needs and religious needs. The home also accepts referrals from other ethnic groups. Sydenhurst DS0000013811.V253510.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): 8,9,10,11 The residents’ health needs are met appropriately however; further work is required to ensure that staff members follow the homes policies and procedures regarding the administration of medication. Policies and procedures are in place supporting the residents’ right to respect, dignity and the right to be treated with sensitivity at the time of their death. EVIDENCE: The manager informed the Inspector that the home has good relationships with a variety of local health and social care teams including; a psychogeriatrician, (a specialist in the health needs of older people) who visits the home every quarter to re-assess specified residents and a community psychiatric nurse from the local mental health team also makes regular visits to the home to talk to those residents they are responsible for. An agreement has been made with the local doctor to provide a surgery at the home one morning a week as well as providing home visits when required. The dental needs of the majority of residents had, to date, been met through visits to the home by the dentist. The manager advised that the dentist had assessed and was providing for the needs of a number of the residents and will Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 Page 10 be assessing the remaining residents as soon as possible. The Inspector was informed that some residents would still need to attend the dental surgery depending on the outcome of the assessment. The home has had difficulties in gaining chiropody support and was using a number of local options to meet the needs of the residents. The manager stated that from October 2005 a chiropodist would be attending the home on a fortnightly basis providing a service to those residents who require assistance. The Inspector sampled a number of the medication administration records and found a number of gaps in the records. A requirement was made for the home to review the medication administration procedures and ensure the staff members were fully aware of what was required by the procedures. The home has suitable storage facilities for medication. A room on the first floor has been adapted to enable residents to choose to meet the District Nurse and or doctor in private, the room also holds the store of medications and returns for the pharmacist. In order to reduce the risk of medication errors the home was using a system of monthly deliveries. Most of the medication was delivered ready boxed by the pharmacist and staff had received training in the recognition of medication in order that they could check the contents. Pictures of particular medications had been given to the home to aid this process. The home had policies and procedures in place to ensure residents were treated with respect and dignity. Each of the residents’ rooms was lockable and those residents who were able held the key to their own room. The Inspector observed staff treating residents with respect and addressing them appropriately by their given name or full address of Mr or Mrs etc. A policy and procedure was also in place to enable residents to remain at the home, if that was their wish, until the time of their death. Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 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 the following standard(s): 15 The menu provided by the home offers a varied and nutritious diet to the residents. EVIDENCE: The home provides a varied and nutritious diet to the residents. The menus are changed seasonally and reflect the availability of fresh produce. In discussion with the cook and manager the Inspector was informed that the cook would be meeting with the local nutritionist within the week to discuss the winter menu. The nutritionist had been advised that the home is seeking advice to ensure they meet the nutritional needs of their residents during the coming colder months. The dining area was clean and fresh and the tables presented well for lunch. One area of the room had a number of tables put together, the Inspector was advised that this was at the request of a number of female residents who had chosen to sit together at meal times. One specified resident spoken with at lunch stated that they were ‘happy at the home’. The kitchen was clean and records had been kept regarding fridge and freezer temperatures and cooked food temperatures. The Inspector observed fresh vegetables and fruit were available for use. Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 Page 12 The Inspector evidenced menus for a period of four weeks. The main meal was taken at lunch time and is changed each day, the home offers seven alternatives each day to the main meal enabling residents to choose an alternative if the main option is not to their personal preference. The main menu regularly includes recipes that reflect the Ukrainian culture. Although not assessed during the inspection those residents spoken with talked about their forthcoming short break away from the home, a holiday home had been hired by the South coast for a number of residents to use. Photographs were seen of a recent day out to the coast, the photographs had been put on display for all residents and staff to view. The manager stated that the home tries to ensure that all residents, if they wish, have a holiday each year. Those residents who have dementia were said by the manager to have the same opportunity and a number had already enjoyed a break away from the home. Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 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 the following standard(s): 17 Residents’ rights are protected by the policies and procedures of the home. EVIDENCE: The home does not manage the finances of residents. Power of Attorney and Court of Protection options are sought whenever there are concerns regarding the ability of a resident to manager their money. Those residents who are able manage their own money and staff can assist by collecting benefits and passing the total direct to the resident. On occasion the home will loan small amounts of money to residents, these instances are documented and receipts held for the person administering the residents funds at which point the money is repaid. Those residents who are able choose to vote using the postal voting system. A local polling station is not available and transport in such circumstances would be problematic for the home. Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 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 the following standard(s): 24,25, Residents rooms had been personalised and the home continues to work toward meeting the individual needs of residents. EVIDENCE: On the day of the inspection the home was clean and hygienic. A number of residents have continence problems and the home has continues to seek appropriate flooring for those bedrooms affected. For some this has led the home to seek agreement with relatives and where involved the relevant social services team to replace carpeting with non-slip easy clean flooring. The bedrooms seen by the inspector had been personalised by those residents. A full tour of the home did not take place. The Inspector saw a number of specified service users rooms, the communal area and outlying buildings and noted the continuing refurbishment work. In discussion with the homes maintenance person it was clear that the homes plans were well known and the maintenance person spoke enthusiastically about the work ahead and their involvement in the process. Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 Page 15 The home is in year two of their five-year plan of refurbishment within the home and to increase the services available either within the home or grounds. The Inspector was informed of the planned work including the provision of a games area, day centre on site and the nearly completed series of small secluded gardens. The gardens were being provided at the request of the residents. The home provides placements to a number of residents with dementia. In order to ensure the safety of those specified people the home has created a separate unit on the ground floor for use during the day. In discussion with the manager the Inspector was advised that the home were considering adding a ‘swipe’ access to the unit. Observations made on the day by the Inspector supported this option. A recommendation was made that the home follows through on the plan to provide an additional safety device to the entry door of the unit. Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 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 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): 28,29 The target for staff qualifying training had been met and the home had regard for the recruitment practices. EVIDENCE: The home had sixteen care staff of whom 10 had completed their National Vocational Qualification Level 2 and a further four were undertaking the same course. The homes housekeepers undertake a National Vocational Qualification Level 2 in housekeeping. The staff personnel files sampled by the Inspector met the standard and no requirements were made. Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 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 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): 31,32,33,34,36,37, Appropriate policies and procedures are in place with regard to the running of the home. The records kept by the home including staff supervision are held securely. EVIDENCE: The manager is social work qualified and has completed the Registered Managers Award and National Vocational Qualification Level 4 in management. The manager had also completed further training including; medication administration, enabling the manager to assess the staff team and assist them to maintain their training. The manager reports to the Board of the organisation and informed the Inspector that there is a good relationship with the Board and that they are supportive of the refurbishment plans in place. Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 Page 18 During the inspection it was noted that various members of the staff team felt able to approach the manager either to discuss queries arising during the day or just to engage in a brief conversation. In addition the Inspector observed the relatives of some residents feeling able to approach the manager to discuss their concerns. The home has a guest bed available on site for use by relatives in particular circumstances enabling families to spend time together during what may be difficult times. The home had recently taken part in a quality assurance audit and a requirement has been made for the home to forward a copy of the outcome to the Commission for Social Care Inspection (CSCI) for information. A copy of the homes financial projection for 2005 – 2006 was passed to the CSCI for information and no concerns were raised regarding the homes financial viability. Some of the outcomes and comments made by residents during the quality assurance process have been noted in the homes brochure. Insurance cover was in place and in date. The manager documents the dates and times supervision has been planned for each member of staff within the home. On occasion and when requested the manager will also take part in a supervision session alongside another supervisor. Formal notes are kept of each supervision session and they are signed and dated by both parties. Although not assessed during this inspection the Inspector noted that the local Fire Service attended the home on the same day of the inspection. The Fire Service gave the home short notice of their attendance to review the homes fire procedures. The Inspector was able to observe the discussion regarding the homes evacuation policy and procedure and note that the Fire Service, in relation to evacuation, raised no concerns. The electrical certificate noted within the last two inspections is specific to the planned replacement of the fuse boxes. This work had not begun. A requirement remains that once work has been completed the resultant electrical certificate must be sent to the CSCI; however it is noted that the requirement continues due to the need to complete the work and not through non-compliance with The Care Homes Regulations 2001 (as amended). The Inspector sampled a number of the homes policies and procedures including their diversity statement, Equal Opportunities policy, management of pressure sores, continence and health and safety at work. No requirements were made on the findings of the sampling. Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X X X X X X 3 3 X STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 X 3 3 X Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 Page 20 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 Timescale for action 10/10/05 2 OP33 24(1)(2) The registered person must ensure that the procedures for the recording of medication administration are reviewed with staff members. The registered person must 20/10/05 forward a copy of the outcome of the quality assurance audit to the CSCI. 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 OP38 Good Practice Recommendations It is recommended that the home install a safety device to the door into the separate unit for people with dementia. Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 Page 21 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 Sydenhurst DS0000013811.V253510.R01.S.doc Version 5.0 Page 22 - 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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