Inspection on 06/12/05 for Tandridge Heights, Memorial Care Home

This inspection was carried out on 6th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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

Tandridge Heights, Memorial Care... 27/06/06

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 Oxted Surrey RH8 0NH Lead Inspector Lesley Garrett Unannounced Inspection 6th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tandridge Heights, Memorial Care Home DS0000062221.V261083.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. Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tandridge Heights, Memorial Care Home Address Memorial Close Oxted Surrey RH8 0NH 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) 01883 715595 01883 713990 tandridge@barchester.com 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.V261083.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 10 beds are provided for intermediate care. Date of last inspection 2nd August 2005 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 75 older persons, to include service users with dementia, and the provision of 10 beds for intermediate care. Accomodation consists of 3 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. Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second since the home opened in April 2005 and took place over six hours. There has also been a pharmacy inspection and compliance visits to ensure that requirements were actioned. Lesley Garrett, Lead Inspector for the service and Kathy Martin, Regulatory Inspector, carried out the inspection. Beverly Williams, Deputy Director of Operations and Acting Manager, Val Betts, Clinical Manager and Acting Manager for two weeks only and Jean Hiley Senior Nurse were in attendance. The Registered Manager was off sick on the day of inspection. Catherine Kidd, Senior Hospitality Manager joined the group for half an hour to discuss her visit to the home to look at in particular menu choices and service. A full tour of the premises took place and the inspector saw most of the residents and spoke with some in more depth. The inspectors would like to thank the Acting Managers, staff and residents for their time assistance and hospitality during this inspection. What the service does well: This is a purpose built home with a good standard of décor and there were no offensive odours on the day of inspection. The dining rooms looked welcoming and there was plenty of communal space. Most of the residents the inspector spoke with were happy with the service they received and the company are responding to the residents concerns and staff is attending the home to meet with the residents and address any issues. Since the home opened and in the managers absence the home has had the benefit of a senior registered nurse who has been constant and supported the home and has given assistance to the Acting Managers. Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 Page 6 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. Tandridge Heights, Memorial Care Home DS0000062221.V261083.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 Tandridge Heights, Memorial Care Home DS0000062221.V261083.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): 2&6 All residents have contracts and terms and conditions in place. Intermediate care beds are used for their stated purpose. EVIDENCE: All resident’s have contracts in place and are either private or social services and are all signed. The terms and conditions contain all the necessary information. The home has ten intermediate care beds and these are on the second floor. The home had recently recruited a registered nurse and therefore hoped there would now be a head of unit on that floor. The rooms on the second floor are spacious allowing room for the rehabilitation and physiotherapy to take place. The inspector spoke with a couple of these residents and one was looking forward to moving to another home near to where she lives. She told the inspector that being at Tandridge for that short time had shown her that she needed to be cared for now and had enjoyed her stay there. Tandridge Heights, Memorial Care Home DS0000062221.V261083.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): 7 9 & 10 Documentation is in place but not always reviewed monthly. A review of medication handling was undertaken by a CSCI pharmacist inspector who concluded that the home could not demonstrate that medication was administered to all service users as prescribed for them by their doctor and as a result they were potentially at risk of harm. Resident’s are treated with respect and their privacy is upheld. EVIDENCE: The inspectors sampled some individual care plans and the documentation was adequate and of a good standard it was noted that some plans had not been updated on a regular basis. Jean Hiley stated that some nurses did not feel confident to do the evaluations but the inspectors explained these are registered nurses and therefore they should be able to carry out this task alternitively training must be given to make sure regular reviews of the care plans takes place. Trained nurses must be made aware of their responsibilities in line with the registered body for nurses, the nursing and midwifery council. One resident will have his documentation re-written by the acting manager as his needs have completely changed since admission. Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 Page 10 The daily notes need to be written to contain more detail as to the events that may have happened to the resident and for them to run concurrently. Medication stocks and records were sampled and showed that the majority of service users were receiving their medication as intended by their doctors. However one service user was being given medicines from an unlabelled supply, a second was receiving medication at a different dose frequency from that printed on the dispensing label and a third was prescribed a medicine with no directions specified by their prescriber. The staff on duty could not confirm that these service users were receiving the doses their doctors intended. All medication was stored securely for the protection of service users, including that held by service users for their own use. Risk assessments were in place for all those service users whose held and administered their own medicines. The stock of Controlled Drugs held on one unit did not match with the records in the Controlled Drugs register. The returns records showed that these drugs had been returned to service users when they left the home. All bathrooms are en-suite with showers. The home has communal bathrooms also if the residents prefer this. All rooms have a call bell, which is accessible to the resident’s. All bedrooms have a telephone point and resident’s can have their own telephone if they wish but the home also has a phone that is mobile and can be taken to the room if they wish to9 make or receive calls. There are private areas for visitors to meet in private and outside space also. During induction staff are made aware of the homes privacy policy. Tandridge Heights, Memorial Care Home DS0000062221.V261083.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): 12 & 15 The home has an activity programme and an activities co-ordinator. The dietary needs of the residents are catered for but following a few concerns the home was looking to adjust the menus. EVIDENCE: The home has an activities organiser who has a published programme of activities. The first floor has a good ‘rummage room’ with plenty of interesting objects for the residents to touch and games to play. The home has three chefs but the head chef was off sick on the day of the inspection. The other chefs are managing well in his absence. The menus are interesting and varied but there have been some concerns noted recently. On the day of inspection, Catherine Kidd, the Senior Hospitality Manager, was visiting residents and staff to see if the menus could be adjusted slightly to give the residents a slightly simpler menu choice. She was also looking at how the plates are cleared and where items are washed as the residents had said it could sometimes be a little noisy if washing up is done during meal times in the small kitchen in the lounge. Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 Page 12 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 Complaints are dealt with by the manager and are taken seriously by the home. EVIDENCE: Prior to the inspection the inspectors had received one written complaint and two anonymous complaints. These were passed to the home to investigate and the acting manager, Beverly Williams was dealing with them. An independent person had carried out investigations of the complaints and letters were about to be sent out. All information was being kept in separate files. The home has a complaints policy, which the resident’s and relatives are made aware of. Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: All core standards seen during inspection in August. No concerns this inspection. Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 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 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): 27,29 & 30 Staffing levels in the home was sufficient. Recruitment is done according to the homes policy and procedures. Staff is given training. EVIDENCE: There was sufficient staff on duty to care for the service users. The Acting Manager was aware that the staffing levels required constant reviewing as the home became more established and the number of service users increased. The home needs to constantly review the numbers and skill mix as it becomes more established. The home has policies and procedures in place for recruitment and the Acting Manager and Senior Nurse both stated that no one is employed until all the necessary checks are in place. The training co-ordinator was on duty on the day of inspection and was busy doing an induction for a new member of staff. Since the last inspection she had made progress with the training and all was being recorded. Manual handling training had taken place and this just needed to be completed on new members of staff. Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 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 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 The home has had problems with management therefore the resident’s have not benefited from continuity of leadership and management. Some attempts have been made with consultations with residents. Resident’s financial interests are safeguarded. Supervision has started but this now needs to be formalised. EVIDENCE: The Registered Manager of the home was on sick leave and the Operations Manager who was taking day-to-day responsibility for the home was also on sick leave at the time of inspection. There has been an Acting Manager covering with extra support from from the company. The home will have an Acting Manager for two weeks before she is replaced by someone who will then cover on a permanent basis until the Manager returns. Management issues have been a problem making the residents feels anxious Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 Page 16 about who is in charge. A resident had written to CSCI expressing their concern about the situation. The home has only been open since April 2005 and the Manager had started to communicate her wishes and begin to lead and motivate the staff. CSCI will be monitoring the Management situation in the home until it has settled. The home has held resident’s meetings and minutes were taken and the Acting Manager has acted upon some of the issues raised. The home has set up pocket money accounts for the residents if they wish and the administrator deals with this. Residents can keep their own money if they wish and some have a Power of Attorney to act on their behalf. The residents also have access to an independent advocate if they wish and the Manager can organise this. Supervision has begun to take place with the staff but this now needs to be formalised. Conversations are all logged in a file but no formal supervision has taken place since the home opened so this is something that will now need to be concentrated on. Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 Page 17 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 3 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 2 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 2 3 X 1 X X Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 2 Standard OP7 OP7 Regulation 15 15 Requirement The registered persons shall ensure that all care plans are regularly updated. The registered persons shall ensure that the daily notes report on what is happening on a daily basis to the residents and is relevant and clear. The registered persons shall ensure that all regulation 26 visits take place monthly. In the interest of the welfare of service users a request was made at the inspection for a General Practitioner to review and clarify the medication for three specific service users. Medication must not be entered out of the Controlled Drugs register until it leaves the home. The balance in the Controlled Drugs register must reflect the balance in the Controlled Drugs cupboard at all times in order that any misappropriation of medication can be detected. The registered persons shall ensure that formal supervision sessions are started with all DS0000062221.V261083.R01.S.doc Timescale for action 06/01/06 13/12/05 3 4 0 OP9 26 12(1)(b) 31/12/05 14/12/05 5 OP9 13(2) 03/01/06 6 OP36 18 06/01/06 Tandridge Heights, Memorial Care Home Version 5.0 Page 19 7 OP36 18 8 OP38 12 members of staff. The registered persons shall ensure that staff conducting supervision meetings receives the appropriate training. The registered persons shall ensure that all food stored in refrigerators are covered, labelled and dated. 06/01/06 13/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tandridge Heights, Memorial Care Home DS0000062221.V261083.R01.S.doc Version 5.0 Page 20 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.V261083.R01.S.doc Version 5.0 Page 21 - 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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