Inspection on 27/06/06 for Tandridge Heights, Memorial Care Home

This inspection was carried out on 27th June 2006.

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

Tandridge Heights, Memorial Care... 17/12/08

Tandridge Heights, Memorial Care... 06/12/05

Tandridge Heights, Memorial Care... 02/08/05

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

CARE HOMES FOR OLDER PEOPLE Tandridge Heights, Memorial Care Home Memorial Close off Barnetts Shaw Oxted Surrey RH8 0NH Lead Inspector Lesley Garrett Key Unannounced Inspection 27th June 2006 08:00 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 Tandridge Heights, Memorial Care Home DS0000062221.V301429.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. Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tandridge Heights, Memorial Care Home Address Memorial Close off Barnetts Shaw Oxted Surrey RH8 0NH 01883 715595 01883 713990 tandridge@barchester.com 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) Barchester Healthcare Homes Limited Mrs Joy Seymour Care Home 75 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (75) of places Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 10 beds are provided for intermediate care. 2 Beds are provided for named service users under the age of 65 in the category of DE 6th December 2005 Date of last inspection Brief Description of the Service: Tandridge Heights Memorial Care home is a new home, and was registered with the Commission for Social Care Inspection in April 2005. It is owned by Barchester Healthcare Homes Ltd. It is registered for seventy-five older persons, to include service users with dementia, and the provision of 10 beds for intermediate care. Accommodation consists of three floors, the ground floor for service users requiring personal and nursing care, the first floor for service users with dementia, and the second floor for service users requiring intermediate care. A passenger lift accessed all floors. All the bedrooms are single and ensuite. There are large communal areas on all floors, consisting of dining and lounge facilities, and several smaller sitting areas at the end of each wing. There are pleasant secure garden areas with garden furniture, and there is adequate car parking facilities at the front of the property. The fees for the home range between £650 - £1,200. ICT beds are £542. Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over nine hours and was the first key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to 2007. Lesley Garrett lead inspector for the service, carried out the inspection and the, acting manager and the head of the elderly frail unit, represented the establishment. A tour of the premises took place and the inspector saw some service users and spoke to some of them in more detail. A pre-inspection questionnaire was used to write some of this report and the home has been sent some service user survey forms (comment cards) but these will not be ready to assist with the report. Records were also sampled as part of the inspection process including care plans and policies and procedures. This was a positive inspection and the inspector would like to thank the service users, staff and manager for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? The medication procedures in the home have now improved and all requirements from the previous inspection in December 2005 have now been met. Following a residents meeting last year there was a few complaints about the food. The catering manager from Barchester has now become very involved Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 6 and in consultation with the service users now organises the four-week cycle of menus for the home. 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. Tandridge Heights, Memorial Care Home DS0000062221.V301429.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 Tandridge Heights, Memorial Care Home DS0000062221.V301429.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users moving into the home have their needs assessed to ensure the home can meet their needs All intermediate care service users maximise their independence and are then able to return home. EVIDENCE: All service users admitted to the home have a pre-admission assessment. Each head of unit carries these out for the elderly frail, dementia or intermediate care unit. A good assessment is taken and the inspector saw evidence of these. The dementia unit also takes a memory score assessment. Assessments are placed in the service users individual folder and care plans are generated from this. The inspector spoke with two service users on the intermediate care unit who told her that they were both planning for discharge very soon and had been Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 9 there for less than two weeks. A service user on this unit told the inspector “I am very lucky to be here. The staff are very kind and everything is wonderful”. Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 10 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): 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 service users individual plans of care are comprehensive and demonstrate that their health and personal care needs are met. The home has policies and procedures in place for the safe handling of medications and no issues around privacy and dignity were raised. EVIDENCE: The service users individual folders are comprehensive and contain care plans and risk assessments and they are all reviewed monthly and show evidence that service users or their representatives have been consulted. The inspector sampled individual folders from each floor and all were of a similar good standard. The home is in the middle of changing paperwork to a new style but all folders are up to date. The head of unit told the inspector that she now prefers the new system and believes it will work well. Pre-admission assessments were all in place and care plans had been generated from them. Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 11 The home has one G.P practice who visit every week and whenever is needed. The head of unit stated that they had good support from the surgery but service users can use another G.P. if they wish. Support also comes from the intermediate care team. On the day of inspection they were helping with the mobilisation of a service user and organising a discharge. The chiropodist visits every six weeks and the opticians every three months. The home also has access to the community dentist who visits regularly. Any pressure sores that the home has at present have all been inherited from outside facilities and are documented and photographed (with consent from the service user). The home manager documents a monthly audit of this problem and a report is sent to their head office. The home has a privacy and dignity policy and this subject is included in the homes induction. Service users are addressed by their preferred name and this is documented in their individual files. G.P. sees all service users in private any other visiting professionals can also be seen in private. Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 12 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): 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. The home has an activities programme, which service users have knowledge of and families and friends are welcomed, to the home. Service users are offered a well balanced diet and are encouraged to exercise control over their lives EVIDENCE: The home has a full time activities organiser and the programme of events is displayed on the notice board. She will see all service users on admission to find out what they like and dislike and the type of activity they would enjoy. The home has just supplied all the service users with a scrap- book, which will be used to document their activities and life in the home. A record is kept of who all service users that has attended an activity and if it has been enjoyed. The home is about to celebrate their first anniversary with a party to be held in the grounds and many people have been invited to join in. Every Thursday there is a church service and there are visits by the library also. Service users can see visitors in private. Schools visit and sing to the service users and also spend time afterwards interacting with them. Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 13 The inspector observed and was told about the choices service users are given. They can select their menu every day and where they would like to sit to eat. They can take meals in the dining room or in their own room. One service user told the inspector that he preferred to eat in his room. He stated, “if I stay in my room to eat I can continue to watch the television or listen to my music and I enjoy that”. Service users are also given the opportunity to select their own clothes and if they would like a bath or a shower and this is documented. The chef, assistant chef and kitchen assistant were all in the kitchen on the day of inspection. Last year, following a residents meeting, some of the residents had complained about the food. The catering manager for the company became very involved and in consultation with the service users the new chef now has different menus, which have a four-week cycle, and there was no complaints about the food when the inspector spoke with the service users. All foods stored in the fridge were labelled and temperatures for the fridge and freezer recorded. Special diets are catered for example diabetic’s and service users requiring pureed diets. The chef told the inspector that any service user that requires a pureed diet has it presented layered and this looked appetising and attractive. Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 14 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 & 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 complaints policy and concerns are listened to and are acted upon. Service users are protected from abuse by the policies and procedures that are in place at the home. EVIDENCE: The home has a complaints policy, which is available in the service user guide and displayed in reception. A complaints log is kept by the home and the inspector saw this. The home has had two complaints this year and all were investigated appropriately and within the policies timescales. All complaints were resolved. The home also has a protecting adults procedure but this was found not to be in line with Surrey’s procedures. The inspector knew from past experience that this was the policy that was followed by the home and staff had all received training. It will be a requirement at the end of the report for the home to review the safeguarding adults policy and to bring this in line with Surrey. Training had taken place for staff and when the inspector spoke with the acting manager and head of unit they both had a good knowledge of the procedures. Tandridge Heights, Memorial Care Home DS0000062221.V301429.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is well maintained internally and externally and is clean and free from offensive odours. EVIDENCE: The home has been open for just over a year and the quality of the decoration internally and externally is of a good quality and the home is light and airy. The inspector spoke with the maintenance man who works full time and told her that a routine programme of re-decoration would take place when necessary. He does check all rooms every morning and replaces light bulbs at that time if necessary The grounds are tidy and safe and service users on the ground floor with patio doors can access the outside and chairs and tables are in good supply. On the day of inspection the home was clean, hygienic and free from offensive odours. The inspector spoke with a domestic who had started work that week. Induction training had taken place and she was beginning to get knowledge of Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 16 the principles of working in a care home. She said that she was enjoying her job and liked meeting and talking with the service users. The laundry facilities for the home were of a good standard. The inspector did not have the opportunity to speak with the laundry assistant but the head of unit told the inspector that she had training in infection control and had a good knowledge of the procedures. Laundry was placed in individual boxes for return to the rooms and all clothes were labelled for easy identification. Tandridge Heights, Memorial Care Home DS0000062221.V301429.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 at least once during a 12 month period. 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. The staffing levels in the home are sufficient to meet the needs of service users. The home is able to demonstrate that trained and qualified staff is able to carry out their role competently and support service users. The home ensures that adequate checks are completed prior to staff working in the home, which ensures that service users are protected by the homes recruitment policy and procedures. Staff training is carried out on a regular basis. EVIDENCE: There were adequate numbers of staff on duty for the number of service users. The inspector looked at the rotas and numbers were consistent. The unit head stated that the home was still recruiting and the numbers will increase as more service users are admitted to the home. 50 of the care staff has the NVQ level 2 qualifications and more are registered on the course. Two members of staff are also on the programme to do their assessors course. An induction programme is in place for all new recruits and all are registered with the skills for care. The inspector sampled some recruitment folders and found that all necessary paper work was in place prior to them starting work. The application forms for staff that were sampled had no explanations for any gaps in employment therefore that will be a requirement at the end of the report. A member of staff was working following a POVA first check but they were not working with a Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 18 nominated member of staff therefore this will also be a requirement at the end of the report. The home has a full time training co-ordinator who is responsible for delivering and accessing all training needs for the home. All new staff has induction and mandatory training such as manual handling, food hygiene and fire. The home has a programme for training and this is provided free of charge. Tandridge Heights, Memorial Care Home DS0000062221.V301429.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is actively recruiting a new registered manager but the home continues to run the service in the best interests of the service users. Service users finances are safeguarded and their health and safety is promoted. EVIDENCE: The home has no registered manager but the current acting manager has been at the home since December giving the home and service users consistency. The acting manager told the inspector that interviews for the managers post had taken place therefore the vacancy should soon be filled. The acting manager told the inspector that service user surveys are carried out on a regular basis and the results are then fed back to them at their meeting. Tandridge Heights, Memorial Care Home DS0000062221.V301429.R01.S.doc Version 5.2 Page 20 Resident meetings take place every three months and minutes are kept. The home keeps a compliments book and the inspector saw the positive comments that had been made about the staff at the home. The primary care trust do their own surveys for all service users in the intermediate care beds. The responsible individual for the service does a visit every month and the results of these are sent to the Commission. The home does not have a sundries account for the service users. They can but whatever they like to and are then invoiced every month. The inspector saw that all the necessary health and safety checks had been completed by the home and the maintenance kept records for this which included the electrical wiring certificate, Legionella check and fire drills had taken place. Risk assessments were in place for specific areas of the home that included the kitchen and laundry Tandridge Heights, Memorial Care Home DS0000062221.V301429.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 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Tandridge Heights, Memorial Care Home DS0000062221.V301429.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 OP18 Regulation 13(6) Requirement The registered persons must ensure that the homes safeguarding adult’s procedures reflect the Surrey Multi Agency procedures. The registered persons must ensure that any new workers at the home are supervised by a qualified and experienced person and they are on the same shifts until the CRB is returned The registered persons must ensure that any gaps in the employment history of their staff have explanations. Timescale for action 27/07/07 2. OP18 18 11/07/07 3. OP29 19 & schedule 2 27/07/07 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 Tandridge Heights, Memorial Care Home DS0000062221.V301429.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: 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 Tandridge Heights, Memorial Care Home DS0000062221.V301429.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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