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Inspection on 08/01/07 for Capwell Grange Nursing Home

Also see our care home review for Capwell Grange Nursing Home for more information

This inspection was carried out on 8th January 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home offers accommodation in pleasant surroundings with well-tended gardens in the centre of Luton. Throughout what had been a difficult time for the home the company had offered support to the manager and was continuing to do so. The duty rotas suggested that the ratio of staff to service users was adequate at the time of the inspection. Because of the size of the home and because the accommodation is provided on five sites the manager has ensured that there is a senior sister for each house, who she is being training and supporting to take the overall responsibility for the house. Service users are offered a choice of wholesome meals and snacks and drinks are made available between mealtimes. The home is clean and tidy and free of offensive odours.

What has improved since the last inspection?

Staff at the home, under the guidance of the manager, had made a number of improvements. At the last key inspection the home was considered to be a poor service when the rules were applied, because a member of staff had not acted correctly when a service user reported an incident that could have been considered abuse. Since the last inspection, extra training had ensured that the staff had a greater understanding of keeping vulnerable adults safe. The Local Authority had also been proactive in supporting the home to recognise abuse by offering support and training. There was a hobby therapist for each of the houses who was responsible for the range of activities provided. There was evidence on Hatley House that when the staff reviewed care plans they did it in a planned way and considered the holistic needs of the service users.

What the care home could do better:

At the end of the inspection the inspector recorded some of the things that the home needs to do better. Because many of the issues raised were known to the manager, and had been part of previous improvements the manager will not be asked to provide in writing how these will be achieved, but compliance will be measured at the next inspection. This is a list of some of the things that must be done better:1. Care plans must be written for all the assessed needs of the service users. 2. Medications must be correctly administered to service users. 3. Any concerns or complaints raised with any member of staff must be recorded and reported to the manager. 4. Areas of the home that need to be redecorated should have this done as soon as possible. 5. Staff training, including that of agency staff, must be recorded in such a way as to provide the evidence that the staff team can meet the assessed needs of the service users. 6. There should be a robust quality assurance system in place.7. All staff should be regularly supervised.

CARE HOMES FOR OLDER PEOPLE Capwell Grange Nursing Home Addington Way Oakley Road Luton Bedfordshire LU4 9GR Lead Inspector Sally Snelson Unannounced Inspection 8th January 2007 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.V323352.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.V323352.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.V323352.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. 5th September 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.V323352.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection focused mainly on checking the compliance with the requirements made at the previous inspection on the 5th September 2006. Where there had previously been compliance, information from the last report was lifted into this report. Sally Snelson, the lead inspector, combined the inspection visit with an interview for the manager Mary Tolladay to become the registered manager. The inspector spent time on Hately House, spoke to the manager, a BUPA regional support manager, staff and visitors and also service users. In addition to information gained during the inspection this report includes information from other sources such as health professionals and social workers. Then inspector would like to thank the staff and the service users for the time and input they gave to the inspection. What the service does well: The home offers accommodation in pleasant surroundings with well-tended gardens in the centre of Luton. Throughout what had been a difficult time for the home the company had offered support to the manager and was continuing to do so. The duty rotas suggested that the ratio of staff to service users was adequate at the time of the inspection. Because of the size of the home and because the accommodation is provided on five sites the manager has ensured that there is a senior sister for each house, who she is being training and supporting to take the overall responsibility for the house. Service users are offered a choice of wholesome meals and snacks and drinks are made available between mealtimes. The home is clean and tidy and free of offensive odours. Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: At the end of the inspection the inspector recorded some of the things that the home needs to do better. Because many of the issues raised were known to the manager, and had been part of previous improvements the manager will not be asked to provide in writing how these will be achieved, but compliance will be measured at the next inspection. This is a list of some of the things that must be done better:1. Care plans must be written for all the assessed needs of the service users. 2. Medications must be correctly administered to service users. 3. Any concerns or complaints raised with any member of staff must be recorded and reported to the manager. 4. Areas of the home that need to be redecorated should have this done as soon as possible. 5. Staff training, including that of agency staff, must be recorded in such a way as to provide the evidence that the staff team can meet the assessed needs of the service users. 6. There should be a robust quality assurance system in place. Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 7 7. All staff should be regularly supervised. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Capwell Grange Nursing Home DS0000017668.V323352.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.V323352.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thorough pre-admission assessments ensured that service users needs were known in advance of them being admitted to the home. The pre-admission assessment also gave the assessor the opportunity to check that the staff team had the necessary experience to provide the care. EVIDENCE: All of the service users who were case tracked had been assessed prior to admission. There was evidence that information gained as part of the preadmission assessments had been used to form the basis of the care plans. The Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 10 pre-admission document was thorough and included sufficient information to provide this information. All the pre-admission assessments sampled had been signed and dated and there was evidence as to how some of the information had been gained. For example comments such as “staff at the hospital suggest” were seen. In addition to the factual information gained, service users had been asked about their general preferences, for example the time they liked to get up and go to bed, and their food likes and dislikes. All of this information had been documented in the care plans. Staff and visitors confirmed that they were given the opportunity to visit the home in advance of an admission. Capwell Grange did not provide intermediate care. Capwell Grange Nursing Home DS0000017668.V323352.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans sampled had been sensitively written and had been reviewed appropriately. EVIDENCE: The care plans looked at on Hately house had been well written. They included sufficient information to ensure that staff could provide the necessary care for the service users. For example, the personal hygiene care plan for one of the service users case tracked indicated how she liked deodorant and talcum powder applied as part of her personal care. This information was provided to the staff by the service users husband and ensured that, because of her dementia, staff would provide the care the service user would want and therefore not cause her undue anxiety. Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 12 There was evidence that the care plans had been reviewed at least monthly and that they had been altered as needs changed. The care plan sampled in detail had been signed by the husband of the service user (because she did not have the capacity to do so herself) following each review. Following each monthly review staff wrote a comment about the aspect of the service users care that was being reviewed. The senior sister for Hatley House confirmed that handover time was used to review service users care so that all the staff team could be involved in the review, even though it was usually the trained staff that recorded the changes. The inspector had been advised that during a recent assessment of care by the Primary Care Trust (PCT) and Social Services, on a service user accommodated in another house, there was evidence to suggest that although this service user had bowel problems, there was no care plan in place in relation to bowel care or management. There was however an entry on the night care plan indicating that she may become constipated. The assessors concluded that ‘there was inadequate information to enable staff to appropriately manage & monitor any intervention’. This same report suggested that there may have been a delay in providing appropriate treatment for this service user when she complained of pain .Prior to the inspection the manager made the inspector aware of this shortcoming and the action she had implemented with the senior staff involved to address it. The care plans sampled confirmed that 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 that should be provided. It was noted that the house had a new lightweight hoist. Staff stated that it was planned to replace all the hoists, in all the houses, with the new lightweight models that were easier to use and manoeuvre. During the inspection a service user became poorly. This sudden deterioration was dealt with appropriately and staff offered her reassurance and moved her to the privacy of her own bedroom as soon as possible. It was noted that the relevant monitoring of vital signs were taken and recorded in a timely fashion. For example, she had a blood pressure and temperature check as soon as she presented with symptoms. A service user who required continuous oxygen therapy, but was confused and wanted to move about more than the tubing would allow, was treated respectfully by the staff and assisted as necessary. Since the last inspection all the beds in the home had been exchanged for profiling beds. These were beds that allowed individual sections to be raised and lowered to suit the needs of the particular service user. For example the Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 13 back of the bed could be raised to allow a service user to ‘sit-up’ in bed. The beds could also be lowered to approximately 45cm above the ground. This option could reduce the need for bedrails; this would be particularly useful for those service users, assessed as needing bedrails, but with a tendency to climb over them and cause damage to themselves. Medication was not looked at in detail during this inspection, as no major problems had been identified at the last inspection. There was evidence that medication rounds were adequately spaced, but also that service users were not woken to take medication if they were sleeping. Since the last inspection there had been a reported incident on Mitre House that a nurse had given the wrong medication. When discovered this had been appropriately reported to the GP and the Local Authority and the service users involved had been monitored closely. The nurse involved had been suspended from duty while an investigation took place. 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. Service users were asked as part of the admission process for their preference as to the gender of the staff that provided their care. Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff were interacting and socialising with the service users, helping to provide them with stimulation. There was a range of activities provided by the activity co-ordinator that service users could participate in. EVIDENCE: Each of the houses had a dedicated hobby therapist who was responsible for supplying and organising the activities for the house. On the day of the inspection the hobby therapist responsible for Hately House was inducting a new therapist who had been employed to work on the younger adult unit. Each house provided a weekly activity programme in addition to a calendar of special social events. The weekly activity programme included one-to–one activities, such as being read to, hand massage and hairdressing. Other Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 15 activities were group activities such as quizzes. Following an activity the activity co-ordinator would document the service users involvement and response to any activity that they participated in. During the inspection, because the service users had a very limited concentration span, a number of different activities were available and service users moved from one activity to another as they wished. One of the activities was designed to encourage service user to reminisce. The newly appointed activity co-ordinator was to work with the service users in the younger adult house. She was aware that her role would involve more trips out and socialising. Because activities were not well funded the co-ordinators had worked together to establish a number of cost saving schemes including sharing resources. Throughout the inspection there was music playing in the background in one of the lounges and the television was available in the smaller lounge. Visitors were given the opportunity to meet with their friends and relatives either in one of the communal rooms or in their bedroom. Visitors confirmed that they were welcomed into the house whenever they choose to visit. There was also evidence that service users could choose what they ate and when they got up and went to bed. The lunch menu was advertised on a blackboard in the dining room. It was noted that staff talked to service users about the menu and encouraged them to make choices before the meal. At lunchtime tables were laid with linen tablecloths and small vases of flowers were on each table. The house sister said this practise was risk assessed as the service users might not recognise the vases as something not to be touched but to date there had been no problems. Throughout the inspection service users were offered drinks with, and between, meals and snacks. Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff were not always reporting to the manager any concerns raised to them, which could result in the appropriate action not being taken. Senior staff were following the homes policies and procedures and reporting any suspicious injuries in order to protect vulnerable adults. EVIDENCE: As stated in the last report, ‘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. 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.’ Since the last inspection there had been a concern raised by a family member, that an issue reported to the senior nurse on duty, had not been dealt with appropriately and the manager had not been made aware. This situation had Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 17 been investigated as part of a Protection of Vulnerable Adults (POVA) procedure and the manager was taking the necessary disciplinary action with the staff involved. All of the staff spoken to had attended POVA training and confirmed that it was part of the induction training. In addition to the regular training the Local Authority adult protection co-ordinator was offering POVA training to all qualified staff. Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,29 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In the areas that had been decorated and refurbished service users were living in a homely environment, but in the houses that had not been updated the environment appeared worn. EVIDENCE: All areas of the home visited were clean and free from any offensive odours. There had not been any major changes to the environment of the home since the last inspection. At that time Milliner House had been redecorated and Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 19 refurbished. There was a need for the other houses to be decorated. The manager confirmed that total refurbishment was part of the plan for the home. Despite the need for redecoration the environment on Hately had been made as acceptable as possible and there were homely touches throughout. However there was little evidence that the house was specifically designed for those service users with a diagnosis of dementia. More attention to this should be applied when redecorating and updating the rest of the home. For example consideration should be given to colour coding the various doors and making areas of the home very different so that a demented service user would easily recognise where they were. As already stated all the service users had been supplied with a new profiling beds. Outside each of the bedrooms on Hately was a small clear cabinet containing a photograph of the service user and a brief description about their life, for example, where they had worked or the name of their husband/wife. There was no evidence that bathrooms and toilets were being used as storage areas. All of the toilets were clearly labelled. Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 20 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. 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 this 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 it was apparent that the home had sufficient staff on duty to meet the needs of the service users. The manager reported that there had been a heavy reliance on agency staff to ensure adequate cover. She was confident that an on-going recruitment plan would address this inn the near future. The senior sister on the unit was also supporting another of the houses but she left 2 more qualified and four carers plus an activity co-ordinator and ancillary staff to cover the morning shift. Staff appeared to have time to talk to service users while providing their care. Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 21 At the last inspection; ‘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’. At this inspection there was evidence that this had started to be addressed but because of sickness had not been fully implemented. It was also difficult to ascertain what training agency staff had had and how they complemented the permanent staff team. During the last inspection staff files were sampled and it was apparent that the home had robust recruitment processes that were audited regularly by the company. The manager confirmed that the same processes were operational and that no staff were employed to work prior to all their checks being completed. Therefore recruitment files were not sampled again as part of this inspection. Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this 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: The manager is a registered nurse with a number of years experience working with older people. She had almost completed the process to become the registered manager for the home. The manager had a clear vision for the Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 23 home, was aware of the importance of disciplining (and praising) staff as necessary and spent time with the staff team and the service users. Outside agencies such as the PCT reported that the manager was open and transparent and that they had confidence in her ability to manage. As stated previously staff spoke highly of the manager and liked her leadership style. One senior member of staff stated, “ She is very fair and always listens and offers advice”. Since the last inspection the home had introduced a monthly quality monitoring system. There was a need for the results of this monitoring and any customer satisfaction surveys, to be published and used to inform the annual development plan for the home. During the last inspection 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. After the last inspection the manager confirmed that the service users could have access to money whenever they required it. 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. The supervision programme had started in the New Year but had to be sustained to meet the standard. No health and safety concerns where noted during this inspection and there was evidence of regularly testing of fire equipment. Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 Standard No Score 16 2 17 X 18 3 2 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 x 2 x 3 2 x 3 Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(1) Requirement Care must be taken that all service users have a care plan for all their needs and that the plan is clear to all the readers. Staff must ensure that staff administer the correct medication to the correct service user at the correct time on all occasions. All staff must record and report concerns raised with them about service users care. The company must ensure that all areas of the home are well decorated and fit for purpose. Training profiles must be in place for all staff and provide the evidence that the staff have the necessary experience and qualifications to meet the assessed needs of the service users. The manager must ensure all staff understands the process of supervision. There must be records to indicate that all staff are being appropriately supervised. Original compliance date of DS0000017668.V323352.R01.S.doc Timescale for action 28/02/07 2 OP9 13(2) 01/02/07 3 4 5. OP16 OP19 OP30 22(1) 23(2) 18(a) 19(5)(b) 28/02/07 01/04/07 01/04/07 6. OP36 18(2) 01/04/07 Capwell Grange Nursing Home Version 5.2 Page 26 01/01/07 extended.Work had started but needed to be sustained now. 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 OP33 Good Practice Recommendations An effective quality assurance programme should inform the annual development plan for the home. Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Capwell Grange Nursing Home DS0000017668.V323352.R01.S.doc Version 5.2 Page 28 - 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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