Inspection on 29/12/05 for Caldwell Grange

This inspection was carried out on 29th 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

Caldwell Grange 06/11/08

Caldwell Grange 14/09/07

Caldwell Grange 27/09/06

Caldwell Grange 27/06/05

Caldwell Grange 28/10/04

Caldwell Grange 20/05/04

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Maple Lodge

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Bank House

Inspirations

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Caldwell Grange Donnithorne Avenue Nuneaton Warwickshire CV11 4QJ Lead Inspector Patricia Flanaghan Unannounced Inspection 29th 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 Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 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. Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Caldwell Grange Address Donnithorne Avenue Nuneaton Warwickshire CV11 4QJ 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) 02476 383779 02476 384798 Warwickshire County Council, Social Services Department Carolyn Gail Eastwood Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: Caldwell Grange is owned and managed by Warwickshire County Council. The home provides care and accommodation for 35 older people with a wide range of needs. The home is situated in a quiet cul-de-sac on a large housing estate in Attleborough, Nuneaton, with many of the service users coming from the immediate local area. There are local shops, a post office, pub, hairdressers and churches located within half a mile of the home. Caldwell Grange provides accommodation on two floors. All the sitting areas are on the ground floor, where there is a large dining room, incorporating a bar, and four lounge areas including a conservatory. The self-contained day care accommodation is available to residents outside day care hours. The home is set in its own grounds with a well maintained and accessible garden area. There is car parking space available for a number of vehicles. Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over three and a half hours between 10.00am and 2.30pm. The inspector also spoke to three residents and four staff, and looked at a range of records. The inspection focused on the requirements arising out of the previous inspection, and the standards relating to staffing and management. A service questionnaire was completed by the home and returned to the Commission for Social Care Inspection (CSCI). The manager was asked to distribute other questionnaires regarding the service to residents, relatives and health care professionals. The completion of these is voluntary but proves useful in assessing the various views that are held. No responses had been received by the CSCI at the time of writing this report. What the service does well: What has improved since the last inspection? A quality officer has also been appointed and is undertaking monthly quality reviews of the services provided by the home. Funding has been allocated to refurbish communal areas within the home as well as three bathrooms. Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 Page 6 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. Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 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 Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 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): None of these standards were assessed at this visit. Standard 3 was reviewed at the inspection of 27/06/05 and found to be met. EVIDENCE: Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 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): 9 Residents are not consistently protected by the home’s policies and procedures for dealing with medicines, which could result in errors being made and risk to resident’s health. EVIDENCE: The arrangement for the management and administration of medications were observed. The following issues were identified and discussed with both the manager and deputy manager: • • • • • • • Not all prn medications specified the reason for administration. A small number of omissions in the administration records. One resident had no medication for three days due to the pharmacist requiring the GP to undertake a medication review before dispensing the prescription. Medications transcribed by hand had not been transcribed in full, i.e. Baclofen. Medications transcribed by hand had not been initialled by staff. Verbal dose changes had not been documented on MARs. Criteria for PRN administration was not clearly defined and recorded on MARs. DS0000035030.V275727.R01.S.doc Version 5.1 Page 10 Caldwell Grange 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 Residents receive suitable meals in pleasant surroundings, which promotes social interaction and wellbeing. EVIDENCE: Meals are served by care staff in the pleasant, large dining room. Meals can also be served in residents own rooms if preferred. Choices are available at mealtimes. Meals were served by care staff and looked well presented. A number of residents spoken with on the day of the inspection commented positively on the quality of the food served in the home. A brief inspection of the kitchen found it to be clean and in good order. Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Systems for the management of complaints are satisfactory residents can be confident that their concerns are listened to, taken seriously and acted up on. There is a clear Adult Protection policy in place, to make staff aware of their responsibilities to provide a proper response to any suspicion or allegation of abuse. EVIDENCE: A detailed complaints procedure is available and accessible to residents, staff and visitors in the home. A resident spoken with advised that he would speak to the manager or her deputy if he had any concerns. The Commission have not received any complaints since the last inspection and the manager advised that they have not received any complaints at the home. The home have in place an Adult Protection Policy, which is in line with the Social Services Policy and the Department of Health document, “No Secrets”. All staff have taken part in Adult Protection Training. Staff spoken to during the inspection were aware of their responsibilities under the Protection of Vulnerable Adults Scheme. Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home is clean, pleasant and hygienic in communal areas. to health were identified in the laundry area. EVIDENCE: At the time of the inspection the home was clean and warm and there were no offensive odours. A tour of the laundry was undertaken. The laundry area is small and it was evident that it is sometimes difficult to maintain an identifiable dirty to clean flow of laundry to minimise the risk of cross infection. The manager said that a new laundry area was in the process of being developed for the home. The following observations were discussed with the manager. • • Clean laundry was being placed in the same baskets that had held the dirty laundry. Colour coded wash baskets specifically for clean and dirty laundry would minimise the risk of cross infection. Clean laundry was stored on the side of the sink. DS0000035030.V275727.R01.S.doc Version 5.1 Page 13 Potential risks Caldwell Grange • • Clean laundry was hanging above and beside dirty laundry by the back door of the laundry. There were no separate hand washing facilities available for laundry staff. At present staff use the large sink which does not have regulated hot water temperature. There are adequate infection control policies and procedures available for the staff. Protective clothing and gloves for staff were evident. The deputy manager advised that many of the staff had recently received training in infection control. Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 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): 28 and 29 Caldwell Grange is adequately staff by people who are well trained. There are robust recruitment procedures in place, which protect the residents. EVIDENCE: Training records examined show that staff have attended regular training on the conditions associated with old age. Fourteen care staff have an NVQ Level 2 in Care with 3 staff members working towards this qualification. Recent training undertaken by staff include The Principles of Care, Dementia Awareness, Infection Control, Protection of Vulnerable Adults, Continence, Stroke, Record keeping and Safe Handling of Medication. Evidence of new staff receiving a clear induction programme was available. The staff files of two recently appointed staff were reviewed and indicated that the registered manager has completed all necessary recruitment checks to ensure the protection of service users. As a matter of good practice the manager keeps a record of all questions asked at interview on file, clearly demonstrating that recruitment is based on equal opportunities. Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 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): 33, 35 and 38 Systems are in place to monitor the quality of the service provided and identify areas in need of improvement. Residents financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: A formal quality system was evidenced. The annual quality assurance survey has recently been completed and the home are awaiting the results. Feedback from residents, relatives and others was also obtained in a less formal manner during reviews and from thank you letters and cards. Many positive comments were seen from appreciative relatives in the comments/complaints book kept in the entrance hall. The Local Authority have addressed the need for the Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 Page 16 registered provider or delegated person to visit the home monthly and write a report, which is also forwarded to the CSCI, on the conduct of the care home. Monies held at the home on behalf of residents are handled in line with the homes policy of handling residents money, ensuring their financial interests are safeguarded. A sample was checked and found to be satisfactory at the inspection visit. Evidence was seen to confirm that staff receive regular training in moving and handling, fire safety, first aid, food hygiene and infection control. Fire alarm tests, emergency lighting tests and fire drills have been carried out at the required intervals. Certificates were seen during the inspection for the maintenance and service of major systems. No health and safety hazards were observed at this inspection. Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 2 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 X X 3 X 3 X X 3 Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 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 Standard OP9 Regulation 13(2) Requirement The registered manager shall make arrangements for the safe handling, storage and recording of medication in accordance with the home’s policy and procedure. A clear audit trail of all medication in the home must be maintained. 2 OP19 23 The registered provider must ensure that the home is kept in good decorative repair. (Part met - carried forward from inspection of 27/06/05 The registered manager must make suitable arrangements to prevent infection and the spread of infection at the home. 31/03/06 Timescale for action 31/01/06 3 OP26 13(3) 31/01/06 Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 Page 19 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 OP26 Good Practice Recommendations It is recommended that the home consider using colour coded laundry baskets for dirty and clean laundry to minimise the risk of cross infection. Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Caldwell Grange DS0000035030.V275727.R01.S.doc Version 5.1 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. 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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