Inspection on 31/01/06 for Capel Grange

This inspection was carried out on 31st January 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

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Capel Grange Maidstone Road Five Oak Green Tonbridge Kent TN12 6QY Lead Inspector Paul Stibbons Announced Inspection 31st January 2006 10:30 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 Capel Grange DS0000065623.V277396.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. Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Capel Grange Address Maidstone Road Five Oak Green Tonbridge Kent TN12 6QY 01892 834225 01892 834225 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) Safequarter Ltd Mrs Sara Grist Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 Brief Description of the Service: Capel Grange is a care home providing personal care and accommodation for 33 older people. The home is located on the outskirts of Five Oak Green, which has a small selection of shops, pubs and other amenities. Paddock Wood is a short distance away where there is a wider selection of amenities and a main line station. The home was opened in 1981 and consists of a large country house with accommodation on two floors with a newer purpose built two-storey extension. A large conservatory has been built onto the older part of the home. The home has 26 single rooms and 3 shared rooms, 23 single rooms have ensuite facilities and all the double rooms have en-suite facilities. There are two passenger lifts. The house stands in its own grounds in three and a half acres of garden, with lawns and paved areas accessible to service users. The home does not have its own transport but minibuses or taxis are booked when required. Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulatory inspector Paul Stibbons conducted this announced inspection from 10.30 – 14.30 on the 31st January 2006. The pre-inspection questionnaire along with 18 service user comment cards, 21 relative comment cards and 2 from healthcare professionals were received by the CSCI prior to the inspection. The inspector spoke with several service users and members of staff during the course of the inspection. A tour of the building was carried out and a number of records and other documentation were examined. What the service does well: 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. Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Capel Grange DS0000065623.V277396.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 Capel Grange DS0000065623.V277396.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): 1, 2, 3 Service users are provided with sufficient information to enable them to make an informed choice as to whether the home will meet their needs before deciding to live there. EVIDENCE: Care plans viewed evidenced comprehensive assessments of service users’ needs that had been carried out by NHS healthcare professionals, care managers and significant others. The home manager and head of care complete their own pre-assessment questionnaire with the service user and their family. Potential service users have access to the home’s Statement of Purpose and service user’s guide for information about the service before committing to a permanent placement. Each service user has a contract stating the terms and conditions of the placement and examples of these were viewed. Capel Grange DS0000065623.V277396.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): 7, 8, 11 Service users’ healthcare needs are fully met and monitored through the use of relevant healthcare professionals. Individual care plans set out their health, personal and social care needs. EVIDENCE: Individual care plans viewed set out the service users’ requirements and there was evidence of referral to relevant specialists where required. Daily records evidence monitoring of service users’ health and well being. The manager stated that the wishes of service users in respect of illness and death are ascertained and the home works sensitively with family members. Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 Page 10 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): 13, 14, 15 Service users are encouraged to make choices about their lifestyle. Family and community contact is promoted and they benefit from a healthy and balanced diet. EVIDENCE: The home arranges a variety of activities for service users, both internally and externally. Examples given were in-house music for health and clothes shows. The home arranges outings to the pantomime, choral services, tea dances and places of interest. A few comment cards received back from service users and relatives stated that they felt there was a lack of activities. The manager stated that resident meetings give the opportunity for suggestions that are often arranged and then not taken advantage of by service users. It is recommended that a record of activities offered is kept and whether they were taken or declined. Another comment card stated “very pleased with the entertainments and other services provided. The staff are excellent at all times”. One comment card stated “in the last 9 months I’ve joined the W.I., go to St. Andrews church and joined an Alfa group. All these people have helped give me back my independence. I even went away to a hotel on my own and enjoyed it”. The inspector spoke with a group of service users in the lounge and all spoke well of the home and staff team, one telling how she attended flower arranging sessions and showed examples of her work. Menus Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 Page 11 viewed indicated a healthy and balanced diet and the inspector observed lunch being served. The meal was well presented and service users’ feedback was positive. One service user, through a third party, had said she was hungry. However, when her comment card was received it stated she was happy with the food given. A discussion with the manager explained that the person in question was a diabetic and staff had to support her with her diet. One service user was refusing to eat and staff were observed trying to coax her into eating and drinking, the GP was called in because of staff concerns about her well being. Comment cards received back indicated that relatives are able to visit at any time and service users commented about going out with their family. Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 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): 17, 18 Service users are protected from abuse and their legal rights are protected. EVIDENCE: The home has robust recruitment procedures and staff files evidence two references and a CRB check are taken up before staff were employed. All staff attended induction training and training around adult protection issues. The manager stated that all service users were on the electoral roll and have access to a postal vote. Service users’ finances are dealt with by their families and arrangements are in place for service users to have contact with a solicitor or accountant should the need arise. Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 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): 19, 26 Service users benefit from living in a clean, safe and well maintained environment. EVIDENCE: The home is spacious with adequate personal and communal space for the use of service users. Two comment cards received back from service users felt that the lighting in the lounge area was insufficient. The manager stated that this issue had been raised and it is planned to introduce additional lighting. Furniture throughout the home was of a good standard and met the needs of service users. Radiators had covers and thermostatic valves and health and safety checks were ongoing in all areas of the home. The Kent Fire and Rescue service is arranging for a full scale evacuation exercise in the near future as a combined training exercise for the brigade and the home, a letter was viewed confirming this. All staff directly involved in the preparation of food have completed a food hygiene course. The laundering of bed linen is done off site and all personal clothing and towels are laundered at the home where there are adequate washing facilities. The home was clean and tidy at the time of Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 Page 14 the visit and free of any offensive odours. One relative comment card received back stated that the shelves in his father’s room do not appear to get dusted. “important things like toilets and basins are kept clean, but corners, skirtings etc. are not. I know that the management are currently advertising for cleaning staff so hopefully this will be a temporary ‘blip’. Otherwise the standard of care at Capel Grange is excellent – and I rate my father’s comfort and contentment far higher than dust!”. The manager confirmed they are currently advertising for additional cleaning staff. Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 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): 27, 30 Service users’ needs are met by adequate numbers of competent staff with the appropriate skill mix. EVIDENCE: A few comment cards received back felt the home could do with more staff. A calculation of the DOH residential forum guidance showed the home to exceed the requirements. There was adequate care staff and kitchen staff on duty on the day of the inspection and the vast majority of feedback from comment cards had not identified a problem. Approximately 95 of the care staff have achieved an NVQ level 2 qualification in care. Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 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, 34, 35, 37 The home is run in the best interests of service users and their rights and best interests are safeguarded by the home’s record keeping, polices and procedures. EVIDENCE: The home actively seeks service users’ views through resident meetings and questionnaires. The home also has quality assurance inspections from KCHA and Investors in People. A notice of this planned inspection was posted in the home and 45 comment cards were received by the CSCI prior to the inspection. The vast majority of the feedback was positive about the service. The home has recently changed ownership and financial and business plans have been viewed by the CSCI. The home provides safe keeping for service users’ valuables if requested, but does not deal with personal allowances, these are dealt with by the families. Records in the home are secure, up to Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 Page 17 date and in good order. Policies and procedures are reviewed on a regular basis. Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 Page 18 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 3 3 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 3 X 3 x Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 Page 19 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. Standard Regulation Requirement Timescale for action 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 OP12 Good Practice Recommendations It is recommended that a record is kept of activities offered to service users and whether they were taken or declined Capel Grange DS0000065623.V277396.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Capel Grange DS0000065623.V277396.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. 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