Inspection on 05/09/06 for Capwell Grange Nursing Home

This inspection was carried out on 5th September 2006.

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

Capwell Grange Nursing Home 24/01/08

Capwell Grange Nursing Home 11/09/07

Capwell Grange Nursing Home 08/01/07

Capwell Grange Nursing Home 10/04/06

Capwell Grange Nursing Home 22/06/05

Capwell Grange Nursing Home 14/04/05

Capwell Grange Nursing Home 01/02/05

Capwell Grange Nursing Home 01/02/05

Capwell Grange Nursing Home 30/11/04

Capwell Grange Nursing Home 30/11/04

Capwell Grange Nursing Home 05/10/04

Capwell Grange Nursing Home 28/04/04

Capwell Grange Nursing Home 23/04/04

Capwell Grange Nursing Home 23/04/04

Capwell Grange Nursing Home 22/04/04

Capwell Grange Nursing Home 20/04/04

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

CARE HOMES FOR OLDER PEOPLE Capwell Grange Nursing Home Addington Way Oakley Road Luton Bedfordshire LU4 9GR Lead Inspector Sally Snelson Unannounced Inspection 5th September 2006 09:00 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 Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 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. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Capwell Grange Nursing Home Address Addington Way Oakley Road Luton Bedfordshire LU4 9GR 01582 491874 01582 564225 edwardscaupa.com www.bupa.com BUPA Care Homes (CFHCare) Limited 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) Vacant Care Home 146 Category(ies) of Dementia - over 65 years of age (60), Mental registration, with number disorder, excluding learning disability or of places dementia (8), Mental Disorder, excluding learning disability or dementia - over 65 years of age (8), Old age, not falling within any other category (120), Physical disability (34) Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can accommodate a maximum of 146 service users of either sex. No one falling into the category of mental disorder (MD) or (MD)(E) may be admitted to the home where there are 8 persons, in the age range of 55 in These categories already accommodated within the home. No person under the age of 55 years can be accommodated in the category of MD. No one under the age of 65 years can be admitted to the home where there are 34 persons already accommodated in the home. 10th April 2006 3. 4. Date of last inspection Brief Description of the Service: Capwell Grange Nursing Home is a modern, purpose built complex comprising of a central two-storey building and five single-storey houses. The central building provides accommodation for administration, reception, and services including laundry, catering, a staff room, staff training areas and a visitors 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, which in some houses is used as a service user smoking area, 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 furniture 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 preparing 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. The fees for this home range from £507.00 per week to £905.00 per week. This is dependent on the funding source and the specific needs of individuals. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second key inspection of the year; the first took place on the 10th April 2006. Two inspectors, Sally Snelson lead inspector and Regulation Manager Sara Morrison inspected for six and a half hours from 9am. The manager was available throughout the morning and a senior nurse, who was deputising in the manager’s absence, for the afternoon. Feedback was given to the senior nurse and the manager was spoken to on the phone the next day. The focus of the inspection was to observe the care provided in two of the houses. One Milliner House, because a number of requirements had been made in the last report that related to Milliner House, and the second Mitre House because it had not formed part of the last inspection. During the inspection the care of four service users was case tracked, two from each of the houses. The case tracking involved looking at the care plans and other documentation of those service users chosen and comparing their records to the care provided to them. This report also includes information from touring the buildings, speaking to service users, staff, and visitors on the day of the inspection and reading documentation and information obtained from various sources since the last inspection. The inspectors also joined the service users for a meal. In addition information from a multi-agency strategy meeting, held following the inspection but before the report was completed was included. Prior to the inspection questionnaires were sent randomly to service users and their families and visitors. Twenty-seven were returned and the information given was used to inform judgements in this report. What the service does well: The home offered accommodation in pleasant surroundings with well-tended gardens in the centre of Luton. The staff worked as a team. One relative wrote on a comment card, ‘One thing I have noticed about Capwell Grange is how friendly and respectful the staff are to my mother. Not just the care staff but cleaners, laundry and maintenance men’. The inspectors who were welcomed in to the home by the staff and provided with the necessary documentation and information also noted this. A relative, whose wife’s condition had improved, said, “ I am over the moon with the care staff have provided” Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The houses, particularly Milliner House, had made significant improvements since the last inspection and it is important that this momentum continues. Staff that work with service users with dementia must have training on caring for service users with dementia and must consider this condition at all times, for example when providing meals, activities and care. On Mitre House staff must ensure that they alter care plans as the care needs of the service user change to ensure that the service user is offered appropriate care by all staff. Following a strategy meeting for a service user accommodated in Fidora House it was apparent that the nurse making the preadmission assessment had not been given all the past medical history. Staff must explore all avenues of information to ensure that they have an accurate description of the service users needs before making the decision that their needs can be met. Staff should be offered regularly meaningful supervision sessions that should include the opportunity to discuss aspects of practice and career development. Following the inspection it became apparent that some staff were not reporting unexplained accident and injuries correctly. Please contact the provider for advice of actions taken in response to this Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 7 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 DS0000017668.V304341.R01.S.doc Version 5.2 Page 8 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 Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 9 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): 3,4,5,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The opportunity service users and their relatives had to visit the home before admission, ensured that service users had information about the home. However if staff did not have all the information about the needs of the service user before admission care needs could be neglected. EVIDENCE: All of the service users who were case tracked had been assessed prior to admission. One of the service users tracked in Mitre House had been admitted recently, and it was apparent that his admission had been planned and that his family and social worker had been involved in the decisions made. Information gained as part of the pre-admission assessment had been used to form the basis of the care plans. In addition, the service user had been asked about his general preferences, for example the time he liked to get up and go to bed and his food likes and dislikes. This information had been documented in his care plan. However following the inspection visit, a strategy meeting held on a Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 10 service user on Fidora, who had presented with unexplained bruising and pain, revealed that the service user had a medical condition that had not been recorded at admission or in her care plan despite there being some reference to it in the documentation sent to the home following her admission. One visitor told the inspector that he visited a number of homes before deciding that Capwell Grange appeared to be the most suitable. Staff had a good basic knowledge of the conditions of the service users and were committed to learning more. Staff had received dementia care training as part of their induction. The senior nurse on Milliner did not have a recognised dementia qualification but had a good understanding of the condition and was updating her awareness by attending a variety of training courses. Capwell grange did not offer intermediate care. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10,11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Care plans that were not reviewed as care needs altered, or as additional information was gained, put service users at risk of receiving the wrong care. EVIDENCE: The care plans sampled on Milliner House had been written to include all the care needs of the service users. These plans had been reviewed and updated accurately. However on Mitre the care needs of one of the service users had changed and although all staff were aware of these changes, and were delivering appropriate care, the initial plan did not support this. The daily log had been accurately completed. At the time of the inspection the service user was not at risk as the staff were aware of his needs and were communicating the changes to each other but should, for whatever reason, the permanent staff not be available, new staff would not be aware of the changed needs and would provide care as per the care plan, which would be the wrong care. Following a multi-agency strategy meeting for a service user in Fidora House it was apparent that information that should have been available at admission, Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 12 but had not been sent to the home until after admission, had not been included in the care planning process. This had resulted in a delay in the service user receiving the correct care. All of the service users had been screened and risk assessed as necessary. Where indicated additional equipment had been supplied. For example, in the care plan of one service user it was apparent that a raised Waterlow score had led to an assessment of the type of pressure relieving mattress provided. Another service users needs assessment had highlighted the need for an assessment by the OT department for a specialist chair. Service users who, following risk assessment, required bedrails had had these provided. These service users had a signed consent form for this form of restraint. The medication was sampled in Mitre House. It was noted that the ordering, administration and documenting of medication was accurate. Staff had signed for all the medications given including the administration of lotions and creams that were applied outside of the usual medication times. The early morning medication round was finishing as the inspectors arrived ensuring that the spacing of medication was appropriate. On Mitre unit there was evidence that some service users chose to get up much later and their medication was given accordingly. One service user told the inspector that she had been starting to self administer her medication in preparation for living more independently, but an accident involving the use of her arm and hand had prevented this continuing. As at previous inspections the staff were seen to be treating service users with respect and ensuring their dignity by providing their personal care in their own bedrooms. The inspector was concerned that the file of a service user living in Mitre House included a photograph of a sore but consent had only been given for a head and shoulder photograph. One of the care plans tracked included information about the service users wishes for the end of life. This service users had been admitted since the last inspection and was evidence that the staff had taken note of what was written in the report even when a requirement or recommendation had not been made. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff were interacting and socialising with the service users, helping to provide them with stimulation. EVIDENCE: At admission service users were asked about their preferences, so that their day could be structured to what they liked and were used to. In both houses staff were interacting well with the service users and passing the time of day with them. On Mitre house a member of the care staff was playing games with one of the service users and the hobby therapist had arranged to take two of the service users on a trip to the cinema in the afternoon. On Milliner House the hobby therapist was off on compassionate leave. During feed back the inspectors discussed with the senior nurse how the service users energy could be turned into an activity such as setting the table, or dusting. Also the possibility of having more items lying around the house which could stimulate service users with dementia and give them a purpose for example, cooking utensils or other familiar items. In order for this standard to be fully met service users should have a detailed care plan for Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 14 activities and there should be a record of how they responded to the activity provided. At lunchtime on Mitre House nine service users were in the dining room when the meal was served, others choose to have their meal in their room or did not want their meal at that particular time. In both houses service users were offered a choice of fish crumble or vegetable pasty, both served with a selection of fresh vegetables. In Milliner House, where the service users had dementia, they were offered a visual choice of the main dish and vegetables were served at the table. Service users were settled at the mealtime and appeared to enjoy their lunch; those that had a pureed diet were presented with a plate that looked attractive. Drinks were offered and encouraged during the mealtime and throughout the day. It was noted that one service user who did not want either options was offered a salad, another service user who at coffee time fancied a chocolate biscuit when only plain biscuits were available, had these bought to her from the main kitchen. An inspector joined the service users for lunch and confirmed that it was a tasty hot meal. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 15 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): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Senior staff that were not following the homes policies and procedures for the protection of vulnerable adults were putting service users and staff at risk. EVIDENCE: Any complaints made to the home since the last inspection were logged and kept on file along with information about how they had been or were being investigated. Three of the 27 satisfaction questionnaire responses suggested that service users or visitors did not know how, or to whom, to complain to if they had a concern. The home’s complaints procedure was displayed throughout the home. The manager stated that complaints were positive as long as they were taken seriously and all involved in them learnt from them and moved forward after the investigation. The manager must ensure that when an internal complaints investigations has taken place a verdict of not upheld is only recorded if there is clear evidence for this comment. Where it has not been possible, usually because of the time delay, to make a firm judgement it should be recorded as such. Staff had attended training about the protection of vulnerable adults (POVA) and were aware of the various forms of abuse. However an incident had occurred in the home and the senior nurse on duty had not followed the Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 16 correct procedures resulting in a service users allegation not being dealt with in a timely fashion or in the correct way. The incident had lead to a police investigation and the suspension and disciplining of staff members. At inspection it appeared that incidents such as unexplained cuts and bruises were reported, however at a strategy meeting following the inspection it was apparent that not all unexplained injuries had been reported. The strategy meeting confirmed that in the absence of the manager many of the senior nurses in charge of the home did not report incidents either at the time or retrospectively to the manager. There was evidence that staff attended and co-operated in any subsequent investigations. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Milliner House had been redecorated to provide service users with a homely environment in which to live. EVIDENCE: All areas of the home visited were clean and free from any offensive odours. Since the last inspection Milliner house had been redecorated. New carpets had been laid in the lounge and the walls had been painted and new curtains hung. The house was bright and cheerful and the hobby therapist was covering a wall with a large colourful mural. Ornament had been placed for service users to look at but out of their reach. Each dining table had a small vase of flowers placed on it. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 18 In both Milliner and Mitre houses the practice of using bathrooms as storage areas had ceased. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Robust staff recruitment practises ensured that staff have been checked and cleared as suitable to work with vulnerable adults before they start work. EVIDENCE: During the inspection both of the units appeared to have sufficient staff to meet the needs of the service users. On Milliner there were three qualified staff and four unqualified staff to provide care for the 30 service users. The staff were anxious that this was the right ratio and had to be reminded that there was no correct number but that there had to be sufficient staff on duty to meet the assessed needs of the service users which could mean that peak times of activity, such as mealtimes, required more staff. Staff in both houses were working in pairs to help service users get up and to transfer them from their beds if this is what they wanted. It was apparent that the senior nurse had co-ordinated the workload and were aware of the whereabouts of the staff and what was expected of them. The staff staggered their breaks to ensure continuity of care. As staff files were found to be correct at the last inspection only one staff file was sampled this time, this was the file of a relatively new member of staff. It was found to be complete. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 20 Staff reported being encouraged to attend training both internally and externally including NVQ courses. All of the staff spoken to had recently attended some training but it was difficult to ascertain how this training had met their learning needs and when the training, particularly the mandatory training, needed to be updated. The manager hoped that the recent appointment of a training officer, who would also be a supervisor, would address this and ensure that the individuals training needs were prioritised to meet the needs of the service users. The inspector learnt after the inspection that staff do not have the opportunity to access the Internet at work. Senior nurses, including the manager, had to look up rare medical conditions and latest guidelines on their home computers. This practice was potentially dangerous as it not only relied on good will it assumed senior staff had a home computer. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 21 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): 31,31,33,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. It was clear that the manager was leading the staff and supporting them. The manager had a vision for the home that she was addressing in a planned way. EVIDENCE: A new manager had been appointed since the last inspection. The new manager had previous experience of managing a care home with nursing for the company. She had also worked at a senior level in a multi-site establishment similar to Capwell Grange. The manager had yet to apply to the CSCI to considered as the registered manager of the home. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 22 Staff spoke highly of the manager and liked her leadership skills. One senior member of staff stated, “ She is very fair and always listens and offers advice”. The home had initially introduced a weekly quality monitoring of each of the houses. This had proved unworkable and had been changed to monthly. The inspector was pleased with the level of monitoring and encouraged that problems often identified at inspection had been identified internally and addressed before inspection. The inspector did not see any evidence of a recent customer satisfaction survey that would guarantee that service users, visitors and all the stakeholders involved in the home were happy with the standard of care provided and did not believe that it could be improved upon. Stakeholder audit should also be used to inform the annual development plan for the home. At the last inspection the inspector did not have access to records of the service users personal monies and was concerned that this would mean that the service users would also be denied access to the money if the key holders were absent. The administrator showed the inspector the records relating to all the transactions of service users monies. All of the money was held in one account but each service users percentage of interest from this account was worked out electronically every month and added to the running total. The administrator and the manager held he key that had access to the petty cash. The inspector still remained concerned that if a service user wanted money at the weekend, when the key holders might be off duty, it would be a problem. Staff were still not receiving regular supervision. This was a conscious decision by the manager who had put into place many other good practices and was waiting until staff had been trained about the purpose and importance of supervision and adequate supervisors had been identified before re-introducing staff supervision. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 23 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 1 X X Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14(1) Requirement The person doing the preadmission assessment of a service user must ensure that they have been provided with all the relevant information about the service user. They must also ensure that this information is passed to the staff writing the care plans and caring for the service user. As the needs of a service user change care plans must be altered to reflect the changes of care needed. The manager must ensure that there are meaningful social activities available and ongoing for all service users. Original timescale 30/06/06 There had been work towards meeting this standard that should be continued. 4 OP16 22(1) When investigating complaint internally the manager must ensure that the outcome recorded has been made following a full investigation and DS0000017668.V304341.R01.S.doc Timescale for action 10/10/06 2 OP7 15 (2) 31/10/06 3. OP12 16(2)(m)( n) 31/10/06 10/10/06 Capwell Grange Nursing Home Version 5.2 Page 25 5 OP18 12(1)(a) 6. OP30 18(a) 19(5)(b) 7. OP36 18(2) cannot be challenged. Staff must ensure that all 10/10/06 unexplained accidents, incidents and injuries are reported and documented correctly The manager must ensure all 31/12/06 staff working with service users suffering from Dementia, have the appropriate up to date knowledge, skills and understanding to ensure service user needs are fully met, particularly reflecting choice and safety. Original timescale 31/05/06 There had been work towards meeting this standard that should be continued. The manager must ensure all 01/01/07 staff understands the process of supervision. There must be records to indicate that all staff are being appropriately supervised. Original timescale of 30/09/06 extended although date not yet reached. 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 OP30 OP35 Good Practice Recommendations The home should ensure that senior staff have internet access to enable them to research medical conditions and check guidelines of best practice. The management should ensure that there is a procedure in place to ensure that service users could have access to their money, which is held by the home, at anytime. Capwell Grange Nursing Home DS0000017668.V304341.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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