CARE HOMES FOR OLDER PEOPLE
The Old Rectory The Old Rectory (Ewhurst) Co Ltd The Old Rectory,The Street Ewhurst Cranleigh Surrey GU6 7PX Lead Inspector
Marianne Barham Unannounced Inspection 28th October 2005 11:15 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 The Old Rectory DS0000017630.V252972.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. The Old Rectory DS0000017630.V252972.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Old Rectory Address The Old Rectory (Ewhurst) Co Ltd The Old Rectory,The Street Ewhurst Cranleigh Surrey GU6 7PX 01483 267195 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) The Old Rectory (Ewhurst) Co Limited Mr Patrick Stuart Geoghegan Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (35), Physical disability of places over 65 years of age (35) The Old Rectory DS0000017630.V252972.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The age range may be: 18 to 64 years in the category PD (physical disability) and over 65 years in the category OP. Provision of outpatient treatment, hydrotherapy and physiotherapy in a dedicated unit from the age of 5 years upwards. 24th May 2005 Date of last inspection Brief Description of the Service: The Old Rectory is a large detached property that has been converted and extended into a comfortable, well equipped care home. The home is set within its own large well maintained gardens and is situated close to the village of Ewhurst within walking distance of local shops and amenities. The home provides accommodation and nursing care for up to 33 older people who may also have a physical disability. The home also has a hydrotherapy pool and fully equipped physiotherapy centre and provides a varied programme of therapeutic care and treatment for service users living in the home and to outpatients. Bedrooms are arranged over two floors, accessible by passenger lift or staircase. Most rooms are single, with a few double rooms, and all have en-suite facilities. Communal facilities in the home consist of a large, comfortably furnished lounge leading on to a sunny garden room, a large dining room, an activities area and a further, recently added lounge. All communal accommodation is located on the ground floor. The Old Rectory DS0000017630.V252972.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 carried out at 11.15am by Marianne Barham, lead inspector for the service. The inspection took place over a period of three and one quarter hours and was the second inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The registered manager Mr Patrick Geoghegan was present and a total of seventeen service users, one visitor and five members of staff were spoken with during this inspection. Records relating to the care of service users and the management of the home were also examined. What the service does well: What has improved since the last inspection?
The works undertaken to build and extra lounge and five further bedrooms is now complete and the lounge has been furnished. The lounge looks out over stunning views of the local countryside and provides a comfortable, quiet area for service users to relax in. Service users have now received a copy of the service users guide, meeting a requirement made at the last inspection on 24th May 2005. Service users or
The Old Rectory DS0000017630.V252972.R01.S.doc Version 5.0 Page 6 their representatives now sign the Care plans or a record is made on the plans to show their refusal to do so, as recommended at the last inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Old Rectory DS0000017630.V252972.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 The Old Rectory DS0000017630.V252972.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): N/A These standards were not assessed at this inspection. Please see report dated 24th May 2005 for details on these standards. EVIDENCE: The Old Rectory DS0000017630.V252972.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 and 9 Service users’ health care needs are fully met and they are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: All service users are registered with a local GP and specialist healthcare professionals are accessed through the practice. A nominated GP visits the home weekly for routine appointments and also as needed. The home provides dental care, speech and language therapy, occupational therapy and chiropody and these services are included in the fees. The home also provides physiotherapy and a charge is made for this. Medication administration records (MAR) charts were examined. These were accurately maintained with appropriate information as per Royal Pharmaceutical Society guidelines. The home is in the process of upgrading the medication storage facilities so the medication is temporarily being stored in a vacant room. The Old Rectory DS0000017630.V252972.R01.S.doc Version 5.0 Page 10 All medication was seen to be stored securely and appropriately and is administered by registered nurses who receive regular medication training updates from the home’s training manager. The Old Rectory DS0000017630.V252972.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): 14 and 15 Service users are helped to exercise choice and control over their lives and they receive an appealing, balanced diet that takes account of their individual needs and preferences. EVIDENCE: The home promotes choice for service users in areas of daily living, such as menus, care plans, activities and when they go to bed and get up. Service users spoken to confirmed that they were able to make choices about their lives. The home employs a chef and two kitchen assistants and all meals are cooked on the premises. The kitchen is spacious, very clean and well equipped and the food stocked was seen to be appropriately stored with a good variety of fresh produce in evidence. The dining room is comfortably furnished and the tables are laid with tablecloths and napkins. Meals are served at the table enabling the service users to choose the size of their portions. Service users spoken with said that the food is very good and that they were able to have alternative meals if they disliked the food on the menu. The Old Rectory DS0000017630.V252972.R01.S.doc Version 5.0 Page 12 The home has a four weekly menu and a list of service users likes and dislikes is kept in the kitchen. Menus are reviewed according to the season, taking into account feedback from the service users. The Old Rectory DS0000017630.V252972.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): 18 Service users are protected from abuse by the home. EVIDENCE: The home has a policy and procedure in place for protecting service users from abuse and also a whistle blowing policy. These are clearly written and give precise instruction for staff members to follow. Members of staff are made aware of these policies at induction and through training in-house. The home also has a copy of the Surrey Multi-Agency Procedures and all staff members have signed to show they have read and understood them. The Old Rectory DS0000017630.V252972.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): N/A These standards were not assessed at this inspection. Please see report dated 24th May 2005 for details on these standards. EVIDENCE: The Old Rectory DS0000017630.V252972.R01.S.doc Version 5.0 Page 15 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): 29 The home’s recruitment policies do not protect service users. EVIDENCE: Recruitment records for several members of staff were examined. Many of these did not contain references, proof of identity or work histories and none seen contained all the information required by The Care Homes Regulations (as amended) 2001. All staff members have undergone a Criminal Records Bureau check and records of these are maintained on computer. The shortfalls in the recruitment records have been discussed with the manager and a requirement has been made to address them. The Old Rectory DS0000017630.V252972.R01.S.doc Version 5.0 Page 16 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): 33 The home is run in the best interests of the service users. EVIDENCE: The home carries out quality audits regularly and a business quality and development plan is in place. Views are sought on the service provided from service users, relatives, health care professionals and any other involved people. A survey is sent out periodically requesting feedback on the services provided, the responses collated and any action required put into place. Service users spoken with confirmed that their views are sought, listened to and acted upon by the home. The Old Rectory DS0000017630.V252972.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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X The Old Rectory DS0000017630.V252972.R01.S.doc Version 5.0 Page 18 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 29 Regulation 19 (4) (b) (i) Requirement The registered person must ensure that all information and documentation as detailed in Schedule 2 (paragraphs 1-9) of the Care Homes Regulations (as amended) 2001, is held in the home for each member of staff employed to work in the home. Timescale for action 28/12/05 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 The Old Rectory DS0000017630.V252972.R01.S.doc Version 5.0 Page 19 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
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