Inspection on 26/01/06 for Collingwood Grange Nursing Home

This inspection was carried out on 26th January 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

Collingwood Grange Nursing Home 02/06/08

Collingwood Grange Nursing Home 14/06/07

Collingwood Grange Nursing Home 31/05/06

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Collingwood Grange Nursing Home Collingwood Grange Close Camberley Surrey GU15 1LD Lead Inspector Denise Debieux Announced Inspection 26th January 2006 10:00 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 Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 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.V268594.R01.S.doc Version 5.0 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 BUPA Care Homes (AKW) Ltd Mrs Lynda Ann Garner Care Home 90 Category(ies) of Old age, not falling within any other category registration, with number (80), Physical disability (10) of places Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 80 beds providing nursing care for older persons. 10 beds providing respite care for people from the age of 20 years with a physical disability 5 beds providing palliative care in the category TI(E) 1 bed providing palliative care in the category TI over the age of 55 years. 12th July 2005 Date of last inspection Brief Description of the Service: Collingwood Grange is a seventy five bedded care home that provides nursing care. It is a substantial property, which is within easy reach of Camberley town centre. There are other amenities in close proximity, such as churches and a hospital. The accommodation for the service users is provided on three floors with seventy-five rooms, all with ensuite facilities. There is a passenger lift to all floors. The communal living spaces consist of a number of lounges throughout the building, some which provide quiet areas for service users to spend time in if they wish. There is a dining room on each floor where service users eat their meals, or if preferred, service users can eat in their bedrooms. There is a separate smoking room for service users to access. Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 8 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service and Sarah Radlett, Regulation Inspector. Ms Judith Brunskill (new Manager) was present as the representative for the establishment. Prior to the inspection, survey forms were sent to the home and distributed to service users, with three being returned, to their relatives, with three being returned, to GPs, Care Managers and health and social care professionals, with one being returned. The results of these surveys and comments made are used in this report. Seven service users and two relatives were spoken with in private. A tour of the building took place with five on-duty staff being spoken with during the tour. The menus, care plans, staff rota, staff files, maintenance records, policies and procedures were all sampled. The inspector would like to thank the service users, visitors and staff for their time, assistance and hospitality during this inspection and the service users, their relatives and health and social care professionals who participated in the surveys. What the service does well: What has improved since the last inspection? What they could do better: Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 6 Requirements have been made regarding service users’ care plans, staffing levels, staff training and staff recruitment procedures. 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. Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NONE EVIDENCE: Standards 3 and 6 were assessed and met at the last inspection and were not addressed on this occasion. Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 The home needs to ensure that all service users have an up to date, individual care plan that details the care required to fully meet all aspects of their health, personal and social care needs. Service users feel they are treated with respect and that their right to privacy is upheld. EVIDENCE: All service users are registered with local GP’s and are able to access other health care professionals such as physiotherapists, occupational therapists and hospital consultants via GP referrals. The care plans sampled during this inspection were based on comprehensive pre-admission assessments, although these were not always fully completed or signed by the person completing the form. The care plans sampled did not include all areas of identified needs or all newly identified problems. No care plans included social care needs and none sampled had been signed by service users or their representatives to signify their agreement with the contents. The care plans were signed on a monthly basis to signify review, however, some of those sampled, whilst signed as reviewed, had not been updated to reflect the current situation. Comprehensive risk assessments had been completed covering all areas of risk, however, some had no service user name, Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 10 some were not signed or dated, others had not been recently reviewed. The staff write on a daily report sheet for each service user but the daily notes do not always relate to or evidence that the service user’s needs are being met. The above issues were discussed at some length during this inspection and a requirement and recommendation has been made. During the tour of the home staff were observed to always knock before entering the service users’ bedrooms and all service users surveyed and spoken with stated that they felt their privacy was respected, with one answering ‘sometimes’. Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 11 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): 15 Meals are well-balanced and varied with individual choices and preferences catered for. EVIDENCE: Menus for four weeks were inspected and seen to be varied and well-balanced. The lunchtime meal was taking place during the inspection and the food was presented in an appetising manner. Ample staff were present and offered help or assistance where needed in a discreet and sensitive way. The atmosphere in the dining rooms on the day of inspection was convivial and unhurried. One service user commented on how much they enjoyed the soup and appreciated the different choices of meals available. Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 All required policies and procedures are in place to ensure that service users are safeguarded from harm or abuse. EVIDENCE: Copies of the complaints procedure were available in the reception area for visitors and all service users have been provided with a copy. The complaint’s log was seen and all complaints were clearly recorded with details of actions taken and copies of any correspondence. The manager is conversant with the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults and the home has a copy of the local procedures. Protection of vulnerable adults is included in the home’s induction training, which is provided to all staff. Being new to Surrey, the manager has yet to attend the Surrey procedure training and a recommendation has been made that a place is sought on the next available course with a requirement that all staff are made aware of and have access to the Surrey procedures. 90 of service users surveyed and spoken with stated they felt safe at the home with one adding ‘Very’. Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NONE EVIDENCE: Standards 19 and 26 were assessed and met at the last inspection and were not addressed on this occasion. Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 14 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 and 30 The staffing levels need to be reviewed to ensure that the needs of all service users are met at all times. Action must be taken to improve the staff recruitment procedures to ensure that the service users’ safety is protected. The home has a staff training programme which is designed to ensure, as far as reasonably possible, that service users are in safe hands at all times but needs to devise a plan to increase the percentage of staff trained to NVQ level 2 in care. EVIDENCE: Of the three relatives that returned comment cards, all stated that they did not feel there were always sufficient numbers of staff on duty with additional comments made by service users that sometimes they have to wait for assistance, especially around mealtimes and after meals. At present there are a high number of service users that require different levels of supervision or assistance with meals. Staffing levels were looked at and discussed in some depth during this inspection. The Residential Forum system was used to check the staffing numbers for the amount of service users currently accommodated at the home and the rota reflected the required level apart from the hours between 7 and 8am and 8 and 10pm, which need to be increased. A requirement has been made that staffing levels be reviewed. The home is currently working towards the target of 50 of staff being qualified to the National Vocational Qualification (NVQ) level 2 or above in Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 15 care. At present 12 of the 44 care staff have obtained the qualification and 4 are currently undertaking the course. A requirement has been made that the home devise an action plan showing how they plan to achieve the 50 target. Since the last inspection, steps have been taken to ensure that required checks have been carried out on all staff at the home but this process has yet to be completed. Four staff files were reviewed at this inspection and were found to contain much of the information required of the regulations, i.e.: proof of identity, Criminal Records Bureau certificates, two references and medical declarations. However, the files inspected did not all include full employment histories, references were not always verified and gaps in employment were not fully explained in three of the four files. Requirements have been made regarding these issues. BUPA has a strong commitment to staff training with many training opportunities offered to staff in both mandatory and additional training. The home has a comprehensive induction and ongoing training programme which covers all areas required by the Skills for Care organisation (previously TOPSS). Of the ten service users surveyed and spoken with, the majority (seven) were complimentary about the staff and care they received with comments including: • Staff are terrific. • Couldn’t wish for better. • Very kind and understanding. Of the remaining three, to the question ‘do you feel well cared for?’ one answered no and two answered ‘ sometimes’ with five of the ten mentioning staff shortages and having to wait for assistance. The negative comments received were mostly confined to only one of the three units at the home. The manager is aware of this situation and is currently working on solutions and plans to carry out numerous small surveys to enable her to clarify exactly what the issues are. Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 36 and 38 The home has a policy of yearly appraisals and regular staff supervision. All policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff. EVIDENCE: The home’s new manager has been in post since October 2005 and is in the process of applying to become the Registered Manager with the CSCI. Ms Brunskill has been a registered nurse for nineteen years, has over five years management experience in care homes and has recently enrolled on a Registered Manager’s Award (RMA) training course. The home has been through an unsettled period with additional changes to the management of various departments since October including: activities; maintenance and hotel services as well as a new home manager and deputy manager. The manager is working hard towards building the new management team, has a good understanding of the areas in which the home Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 17 needs to improve and feels well supported by the BUPA area management team. All staff have had yearly appraisals and formal supervision at least six times per year. Arrangements are in hand for training to be provided to all new department managers and other supervising staff to receive training in formal staff supervision before formal supervision with all staff is resumed. All required safety monitoring checks, fire drills and safe working practice training and updates have been carried out. Staff were observed to be following appropriate health and safety practices as they went about their work. Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 3 X 3 Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 19 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 OP8 Regulation 14(1) (a-d) Requirement The registered person must ensure that each service user has an individual plan of care and that the plan includes the following: • A comprehensive assessment of needs covering all areas of health, personal and social care needs; • Risk assessments, to include prevention of falls and risk of pressure sore development; • Details of individual needs identified; • Goal/objective for each need; • Actions to be taken to ensure the goals are met; • Daily report writing to evidence that identified needs and goals are being met; • Monthly reviews with newly identified needs or problems promptly added to the care plan; • Signature of service user/representative to signify their agreement with the plan; • All entries to be signed and dated by the staff member DS0000017599.V268594.R01.S.doc Timescale for action 26/04/06 Collingwood Grange Nursing Home Version 5.0 Page 20 2 OP18 3 OP27.1 OP27.3 OP27.4 4 OP28.1 5 OP29.1-6 making the entry. The registered person must ensure that all staff working at the home are aware of and have access to the Surrey Multiagency Procedure for the Protection of Vulnerable Adults. 18(1)(a) The registered person must review the staffing levels at the home and ensure that suitably qualified, competent and experienced persons are working at the home in such numbers to meet the needs of the service users accommodated at any one time, with particular attention being paid to the hours of 78am, 8-10pm and at times of peak activity (i.e. mealtimes). 18(1)(c) The registered person to provide CSCI, Eashing office, with an action plan, with timescales, setting out how the home is to achieve 50 of care workers qualified to NVQ level 2 in care. 19(1)(a-c) The registered person must not Schedule employ a person to work at the 2 care home unless the person is fit to work at the care home and he/she has obtained, in respect of that person, the information and documents specified in paragraphs 1 to 9 of Schedule 2 of the Care Homes Regulations 2001, as amended by The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. This includes any persons brought into the home to provide a service, e.g. hairdressers, chiropodists, clergy people etc. 13(6) 24/03/06 09/03/06 09/03/06 26/01/06 6 OP29.1-6 19(1)(a-c) The registered person must Schedule obtain the information and DS0000017599.V268594.R01.S.doc 26/03/06 Version 5.0 Page 21 Collingwood Grange Nursing Home 2 7 OP36 10(3) 18(1) (c)(i) documents specified in paragraphs 1 to 9 of Schedule 2 of the Care Homes Regulations 2001, retrospectively for each member of staff employed by the company after The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 came into force on 26th July 2004. (incorporating requirements 1 and 2 from previous inspection, timescale of 12/9/05 not met) The registered person must 26/04/06 ensure that all staff carrying out formal supervision receive appropriate training. 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 OP7 OP8 Good Practice Recommendations It is recommended that the manager arrange an in-service with all registered nurses to review the Nursing and Midwifery Council (NMC) guidelines for records and record keeping. It is recommended that the manager enrol on the next available training course on the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. 2 OP18 Collingwood Grange Nursing Home DS0000017599.V268594.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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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