Inspection on 02/06/08 for Collingwood Grange Nursing Home

This inspection was carried out on 2nd June 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Collingwood Grange Nursing Home 14/06/07

Collingwood Grange Nursing Home 31/05/06

Collingwood Grange Nursing Home 26/01/06

Collingwood Grange Nursing Home 12/07/05

Collingwood Grange Nursing Home 03/08/04

Collingwood Grange Nursing Home 21/04/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Collingwood Grange Nursing Home Collingwood Grange Close Camberley Surrey GU15 1LD Lead Inspector Mavis Clahar Unannounced Inspection 2nd June 2008 09:20 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 Collingwood Grange Nursing Home DS0000017599.V365298.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. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Collingwood Grange Nursing Home Address Collingwood Grange Close Camberley Surrey GU15 1LD 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) 01276 670700 01276 670017 beckleyl@bupa.com www.bupa.com BUPA Care Homes (AKW) Ltd Mrs Judith Margaret Brunskill Care Home 90 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0), of places Physical disability (0) Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Physical Disability (PD) 2. Dementia - over 65 years of age (DE(E)) The maximum number of service users to be accommodated is 90. Date of last inspection 14th June 2007 Brief Description of the Service: Collingwood Grange Care Centre is a care home with nursing operated by the BUPA Care Homes Company Ltd. Service provision is for older people of either gender, also older people with dementia and young adults with physical disabilities. Placements may be for long - term, respite or convalescent care. The property is a very large, detached, three - story house with basement laundry and kitchen facilities, situated in three acres of landscaped gardens. It has been converted and extended, affording modern, spacious facilities that tastefully blend with the building’s original period features. The home has a large car park and is located near to Camberley town centre and all community amenities, including medical centres, churches and a hospital. Bedrooms all have en suite facilities and are mostly single occupancy. They are arranged on three floors and accessible by passenger lift. Communal lounges, dining rooms, assisted bathrooms and wheelchair accessible toilets are also provided on all floors. The home has a hairdressing salon. Wheelchair accessible transport is available providing access to the community as part of the home’s varied activities programme. Fee charges range between £900 and £1200 per week. There is an extra cost for hairdressing, Chiropody and personal toiletries. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2stars. This means the people who use this service experience good quality outcomes. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection, (CSCI) was undertaken by Mrs Mavis Clahar on the 2nd June 2008 and lasted for seven hours and twenty-five minutes; commencing at 09:20 hours and concluding at 16:45 hours. The CSCI Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This initially helps us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document was received by CSCI (us) and is referred to throughout the report. The registered manager of the home has resigned and a new manager has been appointed. The new manager of the home is a Registered nurse with many years experience in nursing and managing care of older people. She articulates her responsibility for the clinical guidance and supervision of all trained nursing staff and carers and for the pre assessment of proposed service users wishing to enter the home. There is also a new Responsible Individual (RI) who is in daily contact with the home and supports the team. On the day of the inspection the RI was at the home undertaking the monthly regulation 26 inspection. The manager assisted us with the inspection. The majority of the service users spoken to were able to express their thoughts and feelings about the care they receive. The information contained in this report was gathered mainly from observation by the inspector, speaking with a number of service users, information obtained from the pre inspection questionnaires completed by service users, relatives, and staff, and from information contained within the AQAA. Further information was gathered from records kept at the home. The first part of the inspection was spent discussing and agreeing the inspection process with the manager followed by a tour of the home, which included time spent in discussion with service users, care workers, deputy manager, and the Chef. The manager and staff are aware of the Laws regarding equality and diversity and Equal opportunities and this was reflected in the staff mix. All service users in this home are Caucasian and reflect the population of the area in which the home is situated. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 6 All records sampled were up to date with care plans being signed by the service users or by relatives. One recommendation of good practice was issued on this visit Please see Environment outcomes for full disclosure. The final part of the inspection was spent giving feedback to the manager about the findings of this visit. The inspector would like to thank all the service users, visitors to the home and care staff that, made the visit so productive and pleasant on the day. What the service does well: What has improved since the last inspection? What they could do better: The manager is very new in post and is from another area. Although she has had training in Safeguarding Adults she has not attended the Surrey course. However, she has made contact and has asked to be placed on the waiting list. The information contained in the AQAA was not full enough to give a balanced view of how the home’s overall performance. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 7 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. Collingwood Grange Nursing Home DS0000017599.V365298.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 Collingwood Grange Nursing Home DS0000017599.V365298.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. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Prospective service users and their relatives have the information needed to choose a home, which will meet their needs and service users are being assessed to ensure the home is capable to meet the needs of the service users prior to being admitted into the home. EVIDENCE: Review of service users documents and identified policies demonstrated the home has a policy and procedure on admission and discharge of service users. Within the admission policy all service users must have an assessment prior to being admitted into the home. The Head of Care who is trained in the principles of assessment of service users’ needs based on what the care the home says it will provide carries out all pre admission assessments of service users prior to them being admitted into the home. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 10 Review of a random sample of service user’s files including one recently admitted service user, demonstrated that pre admission assessments are being carried out and relatives were being involved in the assessment process. Collingwood Grange Nursing Home DS0000017599.V365298.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. People who use the service experience good quality outcomes in this area. This judgement has been using a range of evidence including a visit to this service. The home has a good and clear care plan in place for service users and this includes appropriate risks assessments. Which forms the basis for care based on the agreed care needs of the service users and demonstrated that trained staff met service users’ health and personal care needs. The home’s medication policy on receiving, storing and administering of medication was in place and being adhered to thereby ensuring the safety and protection of the service users. Care workers treated service users with respect and maintain their dignity and privacy when delivering personal care. EVIDENCE: The randomly selected care plans were clear and easy to read, identifying risks to service users and detailing how these risks would be managed. The daily worksheets demonstrate service users’ needs were being met according to the agreed care plans. In discussion with service users and care workers it was Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 12 demonstrated that service users care needs are fully met. The service user or relative signed the care plans to indicate their involvement in deciding what care they received. It was evidenced that care staff undertaking the development and monthly review of the care plans also signed and dated them. In discussions with service users on the day of the visit they confirmed they were involved in the planning of their daily care. In discussion with the manager we were told, “the service we provide enable service users to benefit from the involvement of the wider primary health care team”. Information contained in the home’s Annual Quality Assurance Assessment (AQAA) informs us “service users benefit from the involvement of our specialist health professionals who supports us in meeting the needs of our service users”. All service users are registered with a local General Practitioner (GP) of their choice and visits are recorded, with access to specialist healthcare professionals through their GP practice as required such as sight and hearing tests which are carried out on a regular basis; and these visits are also recorded in the service user’s folder. Service users are offered access to chiropody service and weekly hairdressing facilities are available at a cost to the service users. In discussion with the registered nurses and deputy manager, they were extremely proud of the standard of care they provided to all service users in the home. Special mention was made of their Memory Lounge, which is used by service users diagnosed with dementia. This lounge is left open and on the day of the visit service users were observed using the lounge. We were told on the day of the visit that no service user at present was risk assessed as capable to self medicate. However, the home had a policy on selfmedication should it becomes necessary. The AQAA states, “the residents receive their medication according to the home’s policy and procedures.” We observed Registered Nurses administering medication and we were told they have all received training in the receipt, recording, storage handling and administration and disposal of medicines. We observed all medicines are administered from a lockable drugs trolley, which is stored in a locked medication room when not in use. In discussion with the deputy manager we were told, “we keep a controlled drugs register and record fridge temperatures daily”. We evidenced this as correct during a tour of the home. Care staff identified as capable to administer medication are requested to leave a sample of their signature, which is dated in the medication trolley. All service users have a recent photograph included in their personal folder and medication record, to reduce the risk of mistakes happening during medication administration. We observed that care workers wore name badges to enable visitors and service users with memory impairment to be sure of whom they are speaking with; and we also observed Service users being treated in a friendly but respectful manner by care workers. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 13 In discussion with service users who were able to understand the questions, they told us that they are treated with respect and dignity, and that they are able to make their own choice. One service user told us “I am very happy here. Everything is so nice. I have my own room; I can have as much privacy as I want”. Another service user said “We have good staff here; they do not ill treat me”. “I have help to choose my own clothing every day.” However, responses were different in the pre inspection questionnaires completed by service users. Some examples were “on a recent occasion it took twenty minutes to get a response to my bell”. Another said, “Response to my service bell is not good enough particularly when I need the toilet.” These comments were fully discussed with the manager who promised to investigate why call bells are not being answered promptly. We observed equality and diversity issues in the home are addressed in the random sample of care plans reviewed and also in discussion with one service user who informed us they were able to entertain visitors in the privacy of their bedroom without interruption from the staff. Collingwood Grange Nursing Home DS0000017599.V365298.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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Service users lifestyles matched their needs and preferences and where possible they are able to maintain contact with family, friends and the local community. The home supports people to follow personal interests and activities. Service users are able to make choices in accordance with their abilities and were provided with a balanced diet in mostly pleasant surroundings and in an unhurried way EVIDENCE: The home employs two full time activity-co-ordinators who provides a good range of activities based on the individual assessed and agreed needs, including their preferences, cultural beliefs and customs. We were told that wherever possible relatives are encouraged to participate in the planning and carrying out of service users’ activities. The AQAA states, “ This enables clients to have a wide range of activities which are devised according to ability Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 15 and cultural needs.” We observed the activities programme displayed in the reception area of the home, in all the three lounges used by the service users and in the dinning areas. In discussion with both activities co-ordinators, we were told and reviewed evidence that service users activities were person centred. For example one person wanted to attend a music shop to purchase personal music and this was planned and carried through. In discussion with this service user, they were very pleased that their desire to go into town to the music shop was made possible. In another instance we observed where one to one activity time was planned and carried out with a service user who was bed bound. It was obvious that equality and diversity issues were central to service users activities, and the care home supports people to follow personal interests and activities. The C/E Vicar holds monthly services, and the Roman Catholic priest holds weekly services at the home for those service users who are able attend. We were told by service users that they are able to have their friends and relatives visit any time it is convenient for them to visit. We did not observe any visitors to the home on this visit, although the register showed some service users had visitors on the day. Five of the service users spoken to said they had choice in their clothing and sometimes they receive help from their key worker. On the day of inspection all service users observed were dressed appropriately for the weather. We were told “all the meals at Collingwood Grange are prepared fresh on site. Service users have a choice daily and can eat in either the dining room or their bedrooms”. We observed they have created a very attractive and welcoming dinning room; with tables being dressed with freshly laundered and colour coordinated table linen. We were told fresh linen is used every day and daily menus that include two alternative choices to the main courses are displayed for the use of our service users. We observed bowls of fruit were placed in the lounges whilst service users were present, and staff was seen offering drinks to service users. We observed much needed improvements in the décor of all the dining areas, and in discussion with the manager we were told a meeting was planned fir July 2008 to discuss refurbishment of the complete home. A recommendation of good practice was made to send their plan of refurbishment on to CSCI as soon as it was available. The inspector did not sample the lunch, but service users said the food was very good, tasty and the right amount. The inspector observed the presentation of the food was done in a way to stimulate appetite. Some service users had supplements as ordered by their GP or dietician, to maintain body weight or increase appetite. Fruit juices and or wine were served with Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 16 lunch, which was served in the dinning room unless a service user requested to have their meals in their bedrooms. We observed care workers interacting in a friendly but dignified manner with service users during the lunch time, sitting down beside service users and speaking to them whilst helping them with their lunches. In discussion with one service user they told us they were grateful for the help with the meal today as they were unable to control their hand today. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 17 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. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The home has a satisfactory complaints policy and procedure and training in place that evidenced that service users and relatives concerns are listened to and acted upon. Robust Safeguarding adults’ policies are in place to protect the service users from abuse. EVIDENCE: Two allegations were received by CSCI and were directed to Surrey Adults Safeguarding Team for investigation. Records kept by the home on the day of the visit, revealed that they have been investigated and suitable actions were put into pace to prevent a repeat of the concern. The manager told us that since her appointment she has kept in touch with service users on a daily basis and issues raised are dealt with immediately; this reduces the incidents of formal complaints. Service users spoken to said they know how to complain and will do so if they are not happy. Their complaint is always dealt with immediately and they were satisfied with the outcomes. The pre inspection questionnaire demonstrated that the majority of service users said they knew how to complain. The AQAA informs us that the home received thirteen complaints since the last key inspection and all thirteen Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 18 were upheld and responded to within the twenty-eight days as per the home’s policy. The manager told us she has made initial contact with Surrey County Council, asking for a place on the Surrey Multi-agency Safeguarding course as soon as a place is available. We were shown a number of certificates to support her claim that she has completed the Safeguarding courses in her previous employment in another area. It was noted that the home received a number of compliments from relatives of service users commending the staff on their kindness and understanding and for the high quality of work they perform. A copy of the most recent CSCI report was made available in reception for visitors to the home. In discussion with care workers, it was apparent they are aware of the homes’ policy and procedure on Safeguarding Adults and felt secure in the knowledge that if they had to use the whistle blowing procedure the manager and the Owners of the home would support them. During discussion with care workers it became apparent they had a good knowledge on Equality and Diversity issues relating to the service users they were responsible for. A random sample of care workers training record demonstrated that care workers are being trained to undertake the duties of meeting the service users assessed needs, thereby protecting them from abuse. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 19 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 26. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables service users to live in a safe and comfortable environment, which encourages independence, and protect their privacy and dignity. EVIDENCE: The manager told us that the management and staff encourage service users to see the home as their own home. It presents as a comfortable but in need of refurbishment and updating home, which has specialist adaptations needed to meet the service users needs and were serviced and records kept verifying this. Some service users told us in the pre inspection questionnaires “recently the cleaning of the home has been spasmodic and not regular enough. At times dust is visible on furniture surfaces”. In discussion with the manager she acknowledged that this could well be true as for a short period they Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 20 encountered lack of domestic staff due to illness and annual leave. However, this was remedied as soon as possible and that she apologised to service users for this shortcoming. The home has attractive gardens, which are not well maintained and there is good access to the gardens from various parts of the home. We were told that a gardener has only just been employed and that they hope the gardens will return to its former well-kept state for the use of the service users. Service users recorded their disappointment in the pre inspection questionnaire about how the gardens have been neglected and the seats are not kept clean. On the day of the visit we did not see any seats in the garden. We were told they are in storage. It was noted that service users were able to personalise their bedrooms with small items of furniture, paintings on the wall and many family photographs. Generally, the home presents as clean, safe, worn and tiried, hygienic, tidy and free from offensive odours. Random review of care workers training record demonstrated they have had training in infection control and this was evident in the storage of waste. In discussion with the manager we were told there is a meeting planned for July 2008 where they will be planning how to refurbish and upgrade the home. We have requested that they keep CSCI informed of all improvements with timescales and decanting of service users before they start the work. A recommendation of good practice was made on this standard. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 21 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. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of the service users. Service users are well supported by a staff team that recognises and responds appropriately to their diverse needs. EVIDENCE: The home is divided into three units and review of the staff rota demonstrated the number and grade of staff on duty to provide care and attention to service users for any twenty-four period was sufficient to meet the assessed care needs of the service users. Where staffing levels are low for example week beginning 17/06/08, we were shown another “bank staff” rota where staff have agreed to cover shifts. The home has a programme of planned training in place and we were told all members of staff have an individual training record this was verified by the randomly reviewed staff folder audited. The Manager told us over 50 of care workers have obtained the National Vocation Qualification at Level 2 (NVQ L2)”, and in discussion with care workers on the day of the visit they said they had NVQ L2 qualification or were in the process of doing the course and this was evidenced in the random sample of files reviewed. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 22 Care workers are encouraged and enabled to undertake developmental training as well as the mandatory training according to the AQAA and this was verified during review of the home’s training records and care workers files reviewed. All newly appointed staff undertakes an induction programme as recorded and documented in their personal files. The home ensures that staff undertakes the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the manager and care workers and from review of care workers training records Random sampling of care workers file demonstrated the homes recruitment processes are in line with the Care Homes Regulations 2001 Schedule 2 whereby all care workers are Criminal Records Bureau, (CRB) and Protection of Vulnerable Adults (POVA) checked prior to commencing employment, and two written satisfactory references are obtained. Staff files sampled contained the required work history. Care workers are in receipt of terms and conditions of employment as evidenced in their randomly selected files. A review of randomly selected Registered Nurses Personal Identification Numbers verified current registration with the Nursing and Midwifery council. We were told that supervision records were up to date and this was verified during random sampling of care workers files. In discussion with care workers some were able to give examples of how the home applied equality and diversity to the different needs and wishes of the service users in their care, and also within the diverse staff group. Staff files contained their up to date training records and it was noted that Equality and Diversity training was not done. In discussion with the manager she provided evidence that this aspect of training was incorporated into the home’s personal best training programme for all staff. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 23 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 38. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The manager supported by Heads of departments manages the home and works to continuously improve services and provide an increased quality of life for the service users. There is a strong ethos of being transparent and open in all areas of running the home. EVIDENCE: The newly appointed manager is a registered nurse; with many years experience of managing care homes for older people. She is in the process of completing the Registered managers Award. She has had experience in dealing with safeguarding issues in her previous job, but is not experienced in using the surrey multi-agency safeguarding policy. She told us she has made contact with surrey county Council for a place on the next available course. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 24 The manager has demonstrated that she has kept herself updated on issues relating to care of the service users and staff in her charge. In discussion, it was evident she was knowledgeable about the training needs of the care workers to meet identified needs of the service users. There are clear lines of accountability within the home, each member of staff spoken to on the day of inspection aware of their role and responsibilities. We were told that regular residents meetings are arranged and minutes of the meetings are passed to the owners who will action requests as soon as possible. The home does not become involved in service users finance except for service users spending money, which the home oversees. Receipts are kept and logged for all transaction carried out on behalf of service users. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day was properly maintained. Records indicated that fire drills, fire alarm, water temperature fridge and freezer recordings were regularly checked. Random sample of care workers’ training files demonstrated that up to date and relevant training were carried out by care workers to protect service users’ health, welfare and safety. In discussion with care workers they discussed their understanding and implementation of appropriate procedures to safeguard service users. Further more they spoke about their understanding of promoting safe working practices based on their health and safety training. The AQAA stated that equipment necessary for the care of service users are serviced and records kept. In discussion with the managers she was able to evidence this. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 25 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations Inform CSCI of timescale and decanting of service users prior to starting the refurbishment and improvement of the home. Collingwood Grange Nursing Home DS0000017599.V365298.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Collingwood Grange Nursing Home DS0000017599.V365298.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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