CARE HOMES FOR OLDER PEOPLE
Capwell Grange Nursing Home Addington Way Oakley Road Luton, Beds LU4 9GR Lead Inspector
Sally Snelson Unannounced 22nd June 2005 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 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. Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Capwell Grange Nursing Home Address Addington Way Oakley Road Luton Beds, LU4 9GR 01582 491874 01582 564225 edwards.ca.@bupa.com BUPA Care Homes Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Cheryl-Ann Edwards Care home with nursing 146 Category(ies) of OP Old Age - 120 registration, with number PD Physical Disability - 34 of places DE(E) Dementia over 65 - 60 MD Mental Disorder - 8 MD(E) Mendal Disorder over 65 - 8 Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1.The home can accommodate a maximum of 146 service users of either sex. 2. No one falling into the category of mental disorder (MD) or (MD)(E) maybe admitted to the home where there are 8 persons, in the age range of 55 in these categories already accommodated within the home. 3. No one under the age of 65years can be admitted to the home where there are 34 persons already accommodated in the home.. Date of last inspection 14th April 2005 Brief Description of the Service: Capwell Grange Nursing Home is a modern, purpose built complex comprising of a central two-storey building and five houses. The central building provides accommodation for administration, reception, and services including laundry, catering, a staff room, staff training areas and a visitor’s suite. There is ample parking for staff and visitors. Two of the houses, Milliner and Hatley provide care for elderly service users with a diagnosis of dementia. Two others, Fidora and Bonnetti accommodate frail residents who require both nursing and social care. These four houses are all registered for 30 service users. The fifth house, Mitre, is registered for 26 service users under the age of 65 years with a physical disability. Staff providing care are qualified nurses and care assistants supported by ancillary staff. Each house has a small quiet lounge, an open plan lounge, a conservatory and a dining area. There is access to the well-tended gardens. The service users individual accommodation has en suite facilities and suitable furnitur and fittings. All rooms have an emergency call system. There are separate toilet and bathing facilities available with access to aids for assistance. Main meals are prepared centrally and each house has a small kitchen for preparaing and serving food and drink. Capwell Grange promotes activities and entertainment for service users by employing a designated Hobby therapist for each of the houses.
Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of the inspection year. Since the first inspection the home had been subjected to regular monitoring visits from the CSCI and observation visits from the Local Authority and the Primary care Trust (PCT). The inspection took place 22nd June 2005 over a period of six and a half hours. The inspector, Sally Snelson, had carried out the last inspection and the majority of the monitoring visits. The homes manager, Cheryl Edwards, two BUPA support managers, Ann Salt and Angela Fawcett and a BUPA quality assurance manager, Chris Rawlings were present throughout. The inspector discussed issues as they arose with these senior members of staff and also fed back to them at the end of the inspection. What the service does well: What has improved since the last inspection?
Since the last inspection a number of changes to care practises had been made. Service users were better assessed and their needs thoroughly documented. This ensured that service users received the care they needed. Service users were asked about their preferences and likes, for example, what
Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 6 time they liked to get up or go to bed. Some service users were now not routinely got up in the early morning by the night staff and put back to bed during the afternoon. Mealtimes had been altered. Lunch was earlier, which meant the meal did not have to be so rushed in order for it to be finished before the morning staff went off duty. Menus had been reviewed and altered to provide a nutritious diet. Service users were now offered frequent drinks and snacks in addition to three meals a day. All staff had been offered a variety of different training. The senior staff on each of the units had been supported to take responsibility for the day-to-day running of their house and report via weekly sisters meeting to the manager. All staff had been made aware of the signs of all forms of adult abuse and what to do if they suspected a service user had been abused or was at risk of abuse. The manager was aware of incidents that were reportable either to the regulatory body or to the social service department. Since the last inspection all staff were aware of their duty to respond to concerns or complaints, made to them, by service users or visitors to 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. Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 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 standard(s) 3,6 The home had developed a new pre-admission assessment tool that would ensure that only those service users who needs could be met, and for whom the home was registered, would be admitted. EVIDENCE: Following the last inspection the registration certificate had been altered to ensure that it accurately reflected the service users who the home could, had and would wish in the future, to admit. There had been no admissions since the embargo had been lifted but the manager was confident that the new pre-admission assessment tool would ensure that only those service users whose needs could be met at Capwell Grange would be admitted. The inspector was shown an assessment that the manager undertook to ascertain if a service user who had been admitted to hospital was suitable to be re-admitted to the home. As part of the case tracking methodology the inspector noted that a service user was not residing in the bedroom she had been first admitted to. There
Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 9 was no indication as to why this move had been necessary, who had agreed it and if the contract had been changed at the point of moving. The quality assurance manger confirmed that it was not normal practice to change a contract when moving a service user. The inspector had not looked at contracts as part of this inspection but could conclude that the contract did not include the number of the room to be occupied or it would have been necessary to issue a new contract when moving a service user. The inclusion of the number of the bedroom to be occupied, is to safeguard service users from being moved simply to meet the staff or the homes needs when it is not necessarily in the service users best interest. Capwell Grange did not offer intermediate care. Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 Detailed well written care plans ensured that the health needs of service users could be met. EVIDENCE: Since the last unannounced inspection each of the service users care files included a sheet that detailed their preferences and choices. Comments such as:- she likes her hair short but not too short, or, she would like to get up at 8am were included. This ensured that staff could meet the wishes of the service users. The relatives of those service users who were unable to communicate were asked to respond to these type of questions and the information they provided was documented. In all of the houses there was evidence that the majority of the care plans had been rewritten or added to. For example there were now clear and concise plans for conditions such as challenging behaviour or diabetes. Staff confirmed that they had had additional training on care plan writing. They also spoke of senior staff supporting them to re-write and review care plans. The inspector chose to sample the care plan of a diabetic, if there was one, in each of the houses. It was noted that the staff working on Hatley House had
Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 11 not been regularly monitoring blood sugars. The inspector discussed this omission with one of the nurses who said that it was requested to be done weekly at 6am so was therefore the responsibility of the night staff. There was no evidence to suggest that the day staff had reminded the night staff that this should have taken place or that the day staff had carried out the recording on behalf of the night staff when they noticed the gap. Risk assessments had been well written and included more detail than they had done previously. For example, a risk assessment associated with falls not only covered mobilising but also included information about the correct footwear the service user should be wearing. This showed the inspector that staff were now looking much more holistically at the service users and their needs. Where a service user had become unexpectedly aggressive a risk assessment had been written immediately. This ensured that staff were sure of their role and there was a consistent approach in the way the situation was handled. Sampling of the medication charts suggested that staff were not checking in medication and documenting that the correct supplies were received from the pharmacy. This was evidenced as two new medications that had commenced on the day of the inspection had issue dates seven days in advance. This would have been noted if a check had been carried out at the time of delivery. On one occasion in Mitre House all the 6am medication had not been signed as given. Discussion with one of the service users whose medication had not been signed for suggested that it had been administered but not been documented. As mentioned in the previous section of the report this was again a situation where if staff worked as a team someone else should/would have noticed the omission and it could have been rectified while staff would have recall of the event. As service users were being given personal care staff spoke to them with courtesy and dignity. The inspector overheard a staff member wheeling a service user in from the garden for lunch saying “Mr H are you ready for me to move you” and waiting for a reply before transferring him to the dining table. Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15 Service users wishes for their daily routines and their particular interests were recorded. Activities were organised to provide meaningful opportunities for service users. Additional food and drink throughout the day and night ensured that the nutritional needs of the service users were met. EVIDENCE: It was noted that some of the service users were enjoying the sunshine in the garden, others were playing a game of quoits under the gazebo and another group were doing a quiz. Each hobby therapist had produced a weekly plan of activities for their house. Some of the activities during the week were for large groups, necessitating the various houses to join together; for example the evening before the inspection a local Pentecostal church had visited to lead a service of gospel singing with the service users. A number of the service users commented about this and how much they had enjoyed it. On one of the units a carer was helping a service user to complete a crossword. Drinks were available for those service users sitting outside via a cool box and were being offered very regularly throughout the day in each of the houses. A
Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 13 water cooler had been purchased and plumbed into each of the houses providing service users and staff with a continuous supply of cooled water. The inspector witnessed part of lunchtime on two of the units. The food was delivered to the house in a hot locker. All of the service users were offered the choice of roast pork or breaded quorm fillet with a selection of vegetables. It was noted that service users were encouraged to sit at tables in the dining room. On Fidora House lunchtime was a sociable occasion with staff and service users interacting and talking to each other appropriately. Those service users who required help with their meal were given this help in an unhurried supportive manner. Where service users had to wait for a carer to help them with their meal the meal was not dished up until the carer was ready so it did not become cold. Drinks were offered with the meal on both of the units. During the afternoon large trays of assorted cakes were delivered to each of the houses by a kitchen assistant. One of the service users reported that she had been having cake every afternoon for the last three weeks and hoped she wasn’t going to put on too much weight. Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 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 standard(s) 16 The implementation of a robust complaints procedure would ensure that service users and visitors could expect action whenever a concern was raised. EVIDENCE: Since the last inspection a verbal concern/complaint sheet had been implemented. This sheet was available on each of the houses and was to be filled in immediately a service user or a visitor raised a concern with a member of staff. It was then the responsibility of the nurse in charge of the house to either action the complaint or takes it to a more senior level. The manager would review any complaints or concerns at the weekly sisters meetings. This was a new procedure, however the inspector was able to see that it was already being used and the correct procedure was being followed. There was still an ongoing police investigation taking place. Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 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 standard(s) 19,21,26 The houses had been purpose built ten years ago and while the home did not pose any risk to service users some areas did not offer a pleasing and pleasant environment for service users to live. EVIDENCE: Each of the houses has an office, an open plan lounge/diner that was divided into separate areas, a conservatory and an activity room. Some of the houses had a designated smoking area for service users. The inspection took place on a particularly hot day. Staff had ensured that the ceiling blinds were pulled over in the conservatory and that service users did not spend long periods in the conservatory. The staff had risk assessed having the lounge doors open to allow a through breeze. This had resulted in at least one member of staff stayed close to the open doors to ensure that service users who chose to wander stayed close to the building. It was noted that many of the activities organised by the activity co-ordinators were taking place outside. For example a group of service users were playing quoits and another doing a quiz and enjoying the sunshine at the same time.
Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 16 The home was approximately 10 years old and all but one of the houses had not been fully refurbished. There was a plan to decorate and upgrade the furnishings in the near future. This would be particularly beneficial to the dementia units. It was noted that the staff team in some of the houses had added some extra decorative touches by painting entrance halls and borders around the house; this was particularly noticeable on Bonnetti House. One of the communal toilets on Fidora House was lined with boxes following the delivery of continence pads. The inspector was aware that storage was an issue and pads had to stored safely and discretely at the point of delivery. If it was decided that a communal toilet was not needed and could be better utilised as storage a storage area this would not be a problem but would need the door of the storage area to be relabelled to avoid confusion to service users. There were no unpleasant odours in any areas of the home and all the areas were clean and tidy. Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29,30 The staff that had stayed working at Capwell Grange during the difficult period over the last ten weeks felt positive that the improvements provided the service users with a better quality of life. EVIDENCE: Since the last inspection some staff had chosen to leave Capwell Grange. The home had been pro-active and had organised a recruitment plan and had recruited a number of new staff who were awaiting checks and references before starting employment. In the meantime agency staff were being used. The inspector spoke to two agency staff members, one from a BUPA agency, both had worked in the home for several shifts and had been inducted with information about fire procedures and the homes policies. As part of the inspection the inspector spoke to the member of the human resource team who was doing an audit on the staff personal files. It was noted that she was checking each file to ensure that the information Required by schedule 2 was included. She agreed that it would be fair to report that:‘files were currently being assessed and that any necessary actions were being identified and actioned’. The audit suggested that about 10 of the files had something missing but that there was no consistency in what was missing. None of the staff employed recently had a copy of the working guide as this was being revised. In the week of the inspection, a new maintenance person, a third chef and a supernumerary night nurse had been employed.
Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 18 There were plans for some of the support staff who had been in the home since April to move on and only leave the quality assurance staff to finish their pieces of work. The management had no plans to leave the home unsupported and had a plan of regular visits. There was a strong emphasis on ensuring that all staff receive appropriate training, most was organised internally. Staff confirmed that they were undertaking the mandatory training as well as relevant training in specialist areas. On the day of the inspection, the head of care had arranged for a company to provide wound care training throughout the day for staff groups. Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,35, Additional support and quality assurance audits had ensured that the registered manager had a good understanding of the areas of the home which needed improvements. Action plans detailed how these improvements were to be managed and resourced. EVIDENCE: Senior staff from BUPA had supported the manager over the last two months and there was clear evidence that this had been beneficial to her and that she had grown in knowledge and confidence. She had a clear vision for the home which she was sharing with the nurses in charge of the individual houses at their regular weekly meetings. Visitors felt confident that their views were being listened to and that improvements in the home had enhanced the care and the lives of the service users.
Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 20 The home did not deal with service users finances and would only hold small amounts of money on behalf of service users so that they could, if they wished, pay for small items from the trolley shop or their personal bills such as hairdressing or newspapers. Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 x 2 x x x x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x 3 3 x 3 x x x Capwell Grange Nursing Home I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 22 no Are there any outstanding requirements from the last inspection? 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 8 Regulation 12 Requirement All staff must ensure that documented health care needs are carried out in a timely fashion. All medication coming into the home must be checked and the person checking must document the check. The person administering medication must sign the medication records as proof that it has been given Toilets that are labelled for service users use must not be used as storage space. Timescale for action 15.08.05 2. 9 13,17 15.08.05 3. 9 13 01.08.05 4. 21 23 01.08.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 2 29 Good Practice Recommendations Contracts should include the number of the bedroom the service user is using. If a room has to be changed the contract should be altered. The audit of recruitment files should be completed and the actions put in place.
I51 S17668 Capwell Grange V233566 220605 Stage 4.doc Version 1.30 Page 23 Capwell Grange Nursing Home Commission for Social Care Inspection Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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