Inspection on 31/05/06 for Collingwood Grange Nursing Home

This inspection was carried out on 31st May 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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Collingwood Grange Nursing Home Collingwood Grange Close Camberley Surrey GU15 1LD Lead Inspector Denise Debieux Key Unannounced Inspection 31st May 2006 09:45 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.V297224.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.V297224.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 BUPA Care Homes (AKW) Ltd To Be Confirmed 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.V297224.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 26th January 2006 Date of last inspection Brief Description of the Service: Collingwood Grange is a 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.V297224.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over 7 hours and was carried out by Denise Débieux, Regulation Inspector. Ms Judith Brunskill (Manager) and Mr Amarsingh Nekitsing (Deputy Manager) were present as the representatives for the establishment. A tour of the premises took place. Seventeen of the fifty-six service users and six on-duty staff were spoken with during the visit. In addition, thirteen service user survey forms and two relatives’ survey forms were completed and handed in to the inspector on the day of this visit. Some of the comments made to the inspector and made on the survey forms are quoted in this report. The home had completed a pre-inspection questionnaire and service user care plans, staff recruitment records, incident reports, complaint’s log, health and safety check lists, menus, activity schedule, medication records and storage were all sampled. The lunchtime meal and medication round was observed and the home was toured. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this visit. What the service does well: What has improved since the last inspection? The staff have worked hard and now operate a robust recruitment procedure. The manager has introduced a new position of ‘Home Liaison’ officer at the home. This member of staff has been in post 3 weeks and was previously a senior care worker. Her role is to spend time with the service users and provide a familiar face and an additional link with the management of the home. Her role also includes highlighting to the manager any areas for improvement that may not have otherwise come to her attention. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 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.V297224.R01.S.doc Version 5.2 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): 3, 4, and 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Each service user is only admitted to the home following a needs assessment, but the home must ensure that people carrying out the assessments are suitably qualified and experienced. The home must ensure that service users are not admitted to the home outside of their category of registration and that staff are suitably qualified to meet the needs of the service users currently accommodated at the home. The home does not offer intermediate care. EVIDENCE: Three care plans were sampled from a selection of service users that have been recently admitted to the home. The care plans sampled all contained detailed assessments of the service users’ needs and included information regarding their preferences and previous likes and dislikes. It was noted that one person had been admitted with a diagnosis of dementia, and dual sensory impairment. Whilst the care plan for this person set out the actions that staff needed to take to meet the service user’s needs, there was Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 9 no evidence that these actions were being carried out by staff. The home is not registered to care for people with dementia or sensory impairments and no staff are qualified to assess or plan the care needed by this client group. The inspector visited the service user and spent some time with her. Staff were seen to be friendly and caring towards this service user but were clearly inexperienced in caring for people with dementia and sensory impairments. On two occasions carers came in to the room to check that the service user was ok and didn’t need anything, however they did not identify themselves to the service user and were outside of her very limited field of vision. Unbeknown to the staff involved, and although the checks were being made with the kindest of intentions, the visits only served to scare the service user who asked the inspector who the people were, what they wanted and asked the inspector to stay with her. Requirements have been made and the home must take steps to ensure that the staff at the home are suitably qualified, competent and experienced to ensure that all aspects of the personal, health and social care/activity needs of all service users are appropriately assessed and met. The home must make sure that service users are only admitted within their categories of registration, which is ‘old age, not falling within any other category, with six beds available for people requiring palliative care.’ It was discussed with the managers that the home must take urgent action to have this service user’s needs assessed related to dementia and her sensory impairment needs. The persons carrying out these assessments must be suitably trained and experienced in the care of people with dementia and also the care of people with sight and hearing impairments. The home must also ensure that these assessments include the suitability of the service user’s personal accommodation and the home’s communal facilities and any identified aids and adaptations must be provided without delay. On the day following this visit, telephone contact was made with the home and the inspector was advised, by the manager, that the following steps have already been taken or have been put in motion: • The service user had a full needs assessment the morning after this visit, by the deputy manager from another BUPA home that specialises in dementia care. That deputy manager is drawing up a care plan and will be giving help and guidance to the staff working with the service user. • The manager has made contact with the RNIB (Royal National Institute for the Blind) to arrange for an assessment to be carried out as soon as possible and for help and guidance on the accommodation. • The manager is contacting the service user’s care manager to arrange a review. • Staff are to obtain a full life history with the service user and her family and obtain names for people depicted in the photographs in the service user’s room. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 10 • Interim training for all staff working with the service user regarding her specific needs around dementia care and sensory impairments will be carried out as soon as it can be arranged. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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. Policies, procedures and practices are in place to ensure the safe administration of medication. EVIDENCE: Care plans sampled were comprehensive and set out actions which need to be taken by care staff to ensure that the health and personal care needs of the service users are met. However, as discussed in the previous section, staff assessing and planning care for service users must be suitably qualified and have the appropriate experience. The pre-admission assessments and care plans sampled had been signed and dated by the person completing the forms. However, some other assessment forms (i.e. nutritional assessments, life maps) had not been signed. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 12 Care plans are reviewed on a monthly basis, as are risk assessments. Daily notes are made but do not provide evidence that specific needs are being met or that staff are carrying out the actions identified in the care plans. At the last inspection requirements and recommendations were made regarding the service user care plans. The inspector was told that all care plans had been audited and that the Nursing and Midwifery Council (NMC) guidelines for records and record keeping were reviewed with all trained nurses at a staff meeting. However: • care plans still do not include social care/activity needs; • staff are not relating daily report writing to specific needs or goals and are not demonstrating that needs are being met or that care plans are being referred to or followed; • not all entries are signed and dated by the staff member making the entry; • care plans are not signed by the service users and there is no evidence to show that they have been involved in their care planning. The previous requirement has been carried forward and the home must review all care plans and ensure that steps are now taken for this requirement to be met in full and without delay. In addition, Registered Nurses must take personal responsibility for their own professional conduct and ensure that they are fully aware of and following professional codes and guidelines set down by The Nursing and Midwifery Council at all times. During the tour of the home, staff were observed to always knock before entering the service users’ bedrooms and all interactions observed between staff and service users were seen to be caring and respectful. One service user said that she felt she was well looked after and that the staff ‘really are good girls’. Of the thirteen service users surveyed, ten answered that they always receive the care and support they need, two answered ‘usually’ and one answered ‘ sometimes’. The medication administration records, medication storage, policies and procedures were all sampled and found to be in order. The lunchtime medication round was observed and seen to be in line with the home’s policies and procedures. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living and activities are flexible and varied but need to be more individualised to suit individual service users’ needs and wishes. Contacts with family and friends are encouraged and service users are encouraged and enabled to exercise choice and control over their lives. The meals in this home are good, offering both choice and variety. EVIDENCE: BUPA employ activity organisers in each of their homes. A new activity organiser started work at the home last December but has very recently resigned. In his absence staff are endeavouring to ensure that activities continue without too much disruption. Care staff are continuing the weekly bingo sessions, weekly exercise sessions are continuing and the ‘home liaison officer’ has organised some trips out for service users. The plans for the yearly fete have continued and staff, service users and relatives are all involved in the planning for that day. The inspector congratulates the home on their efforts to continue the activities in the absence of the activity organiser. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 14 Of the thirteen service users surveyed, one said there were always activities arranged by the home that they can take part in, nine answered ‘usually’, one answered ‘sometimes’ and one answered ‘never’. The possibility of employing a locum activity organiser was discussed, as was the requirement for care plans to include individual plans for each service user covering social care needs (see previous section of this report). Hopefully, once this requirement has been fully actioned, all service users will feel that there are activities they can take part in and that their social care needs are being met. There are no restrictions to visiting times and staff support and encourage service users to maintain family links and friendships inside and outside the home. Menus were sampled and seen to be varied and well-balanced. The lunchtime meal (roast lamb) 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. All service users spoken with, and surveyed, were complimentary regarding the meals at the home. One service user did comment that, while she liked the food, the chips were sometimes ‘cold and soggy’ and another said that she did not always recognise the food on the menu and preferred ‘British food’. Both these comments were passed to the manager who stated she would discuss them with the chef. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a simple, clear and accessible complaints procedure which includes timescales for the process. All required policies and procedures are in place to ensure that service users are safeguarded from harm or abuse. But, the home must ensure that all staff are aware of and follow the policies and procedures regarding whistle-blowing and the protection of vulnerable adults. 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 and promptly follows the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults on occasions when possible incidents of abuse have been reported. The home has a copy of the local procedures and a copy of the Department of Health’s ‘No Secrets’ document. However, a member of staff spoken with was not clear of the correct procedure to follow if an allegation of abuse were made to her and a recent situation has highlighted that some members of staff do not work to the company’s ‘whistleblowing’ policy. Currently the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults is kept in the manager’s office and the inspector suggested placing a copy at each nurses’ station. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 16 At the last inspection a requirement was made that ‘The registered person must ensure that all staff working at the home are aware of and have access to the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults.’ This requirement has not yet been fully met and has been carried forward with a limited, extended timescale. The manager stated that she has attempted to book a place on the local, Surrey training course but has been told that there are no places available at present. The previous recommendation has been carried forward to this report. Arrangements have been made for training on the protection of vulnerable adults to be provided to staff at the home. This training is scheduled for June 06 and the inspector was advised that one of the trainers has attended the Surrey local procedure training. Service users surveyed stated that they were aware of who to complain to and knew who to speak to if they were not happy. One service user spoken with answered ‘Oh yes, definitely’ when asked if she felt safe at the home. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home and gardens are suitable for their stated purpose. An ongoing maintenance and redecoration programme provides the service users with clean, pleasant and homely surroundings in which to live. EVIDENCE: The and and and home was toured and found to be well-maintained with fixtures, fittings furnishings of a high standard. The bedrooms seen were all well decorated many contained the service user’s own items of furniture, photos, pictures ornaments. Redecoration of the hallway on the first floor is underway and the carpets are being replaced when the painting has been completed. Each floor has it’s own dining room and lounge and the service users are able to access the grounds freely. The gardens are well maintained with outdoor Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 18 seating provided for the warmer weather. The home has recently employed a new gardener and summer planting is underway. Laundry facilities are provided, with washing machines suitable for the needs of the service users at the home. On the day of this visit the home was found to be warm and bright with a homely atmosphere and a high standard of housekeeping apparent. Service users spoken with were happy with their rooms and all surveyed said that the home is fresh and clean. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing levels need to be reviewed to ensure that the needs of all service users are met at all times, and taking into account the service users’ individual preferences, expectations and capacities. The home now follows robust staff recruitment procedures which incorporate all areas needed to ensure, as far as reasonably possible, that service users are protected from harm. The home needs to devise a plan to increase the percentage of staff trained to NVQ level 2 in care and provide training to staff specific to the needs of service users accommodated at the home (with reference to service users with dementia and/or sensory impairments). EVIDENCE: At the previous inspection, concern was raised by a number of service users and relatives that there were not enough staff, especially around mealtimes and more so on one of the three floors. At this visit, this situation has improved, with the previous issue of staffing around mealtimes having been mostly resolved. Of the thirteen service users surveyed, six stated that there were always enough staff, six stated that there were usually enough staff and one answered there was sometimes enough staff. Service users spoken with all said there were usually enough staff but that they were always busy, especially in the evenings, with one adding that it would be nice if staff could stop and talk instead of having to rush off. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 20 The inspector suggested that care plans could be kept in the service users’ rooms and that, instead of sitting at the nurse’s station to do paperwork, staff could go to the individual service user’s room to write their daily notes and update care plans. This would also enable the service users to be more involved in the planning of their own care and to have more opportunities to chat to staff. At the previous inspection, a requirement was made that the home review their staffing levels, especially for the hours between 7 and 8am and 8 and 10pm. At present the day shift finishes at 8pm and hand over to the night shift is from 8 – 8.30 pm. The night shift is made up of one trained nurse and one carer on each of the three floors, with an additional carer on the ground floor. The inspector was advised that, out of the current fifty-six service users, forty-three service users need the assistance of two care staff to go to bed. With the day staff all leaving at 8pm and the staffing after that time reduced to a total of seven, this is limiting the service users’ choice of what time they retire, especially if their preference is to go to bed between the hours of 8 and 10pm, and also means that others have to wait for two members of staff to be available. The requirement made at the last inspection has been carried forward and the manager has been asked to review the staffing levels again, especially between 8 and 10pm, taking into account the service users’ individual wishes, preferences and rights to choice. There has been no change to the percentage of service users qualified to NVQ level 2 in care (24 ) since the last inspection. The inspector was advised that this is because there are some care workers who do not wish to undertake a formal training course and that others do not meet the criteria for local funding (although this does not exclude them from undertaking the training). The National Minimum Standards expected 50 of staff to be qualified to a minimum of NVQ level 2 by 31st December 2005. At the last inspection a requirement was made for the home to draw up an action plan showing how they plan to achieve 50 of their carers qualified to the required level. Although the action plan was drawn up and provided to CSCI, the plan is not working and the home must now revisit this issue and develop an effective plan for improvement. The recruitment files for three members of staff were sampled. These were found to contain all required documents and information. Since the previous inspection the home have revised their recruitment practices and the manager and administrator now take great care in ensuring that all information is in order prior to making an offer of employment. The inspector congratulates all staff involved in recruitment for their success in this area. The manager has a copy of the General Social Care Council’s code of conduct and practice for social care workers and now plans to give a copy to all staff. Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 21 BUPA has a comprehensive induction and ongoing training programme which covers all areas required by the Skills for Care organisation (previously TOPSS). The home have recently developed a new post for a training coordinator. The need for the home to ensure that staff are appropriately trained to meet the specific needs of service users accommodated at the home has been dealt with earlier in this report. Collingwood Grange Nursing Home DS0000017599.V297224.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager needs to make an application to become the registered manager. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users. Service users’ financial interests are safeguarded by the policies and practices of the home. Group supervision takes place but the home now needs to fully implement regular, one-on-one formal supervision with all staff to ensure that service user benefit from well supervised staff. All other 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 manager has been a registered nurse for nineteen years, has over five years management experience in care homes and is enrolled on a Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 23 Registered Manager’s Award (RMA) training course. Ms Brunskill has been in post since October 2005 and must now submit an application, to CSCI, to become the registered manager. The new registration application procedure was explained at this visit. BUPA carry out a bi-annual service user survey. When the results have been correlated a report is sent to the home and an action plan is developed to address any issues that are identified. The inspector was advised that the service user survey for Spring has recently been completed and the home are awaiting the report. In order for this standard to be fully met the home will need to expand their quality assurance system to include seeking the views of stakeholders in the community (e.g. GPs, chiropodists, care managers and other health and social care professionals). Following the previous inspection the manager, deputy manager and the heads of departments have now received training in formal supervision. Group supervision takes place routinely during staff meetings but the home now need to fully implement formal, structured one-on-one supervision with all staff. Health and safety records and safety certificates were sampled. All policies, procedures , practices and safety checks were found to be in place and up to date ensuring, so far as is reasonably practicable, the health safety and welfare of service users and staff. Staff were observed to be following these procedures on the day of this visit. Collingwood Grange Nursing Home DS0000017599.V297224.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 2 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Collingwood Grange Nursing Home DS0000017599.V297224.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 OP3 OP30 Regulation 14(1)(a) Requirement Timescale for action 31/07/06 2 OP4.1 3 OP4 OP12.3 OP30 The registered person must not provide accommodation to a service user unless the needs of the service user have been assessed by a suitably qualified or trained person. (With reference to the persons carrying out pre-admission assessments of service users with dementia and/or sensory impairments.) 4(3)(b) The registered person must 31/05/06 12(1)(a) ensure that service users are not (b) admitted outside of their Care category of registration. (With Standards reference to service users with Act 2000 dementia and/or sensory Section 24 impairments.) 31/07/06 18(1)(a) The registered person must (c)(i) ensure that staff are suitably 12(1)(a) qualified, competent and (b) experienced and receive training appropriate to the work they are to perform. (With reference to all staff, including activity organisers, working with, assessing and planning care for service users with dementia and/or sensory impairments.) DS0000017599.V297224.R01.S.doc Version 5.2 Collingwood Grange Nursing Home Page 26 4 OP4 OP12.3 14(1) (a-d) 5 OP7 OP8 OP12.3 14(1) (a-d) The registered person must identify any service users with dementia or sensory impairments and arrange for their personal, health and social care needs to be fully assessed by a person suitably qualified or trained to assess people with dementia and/or sensory impairments. Once completed the registered person must send a report to CSCI, Eashing office, setting out how the home is meeting or plans to meet the identified needs, including the provision of any appropriate aids or adaptations. The registered person must review all care plans and 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 making the entry. (Timescale of 26/04/06 not DS0000017599.V297224.R01.S.doc 31/07/06 31/07/06 Collingwood Grange Nursing Home Version 5.2 Page 27 6 OP18 13(6) 7 OP27.1-5 18(1)(a) 8 OP28.1 18(1)(c) 9 OP29.4 18(4) 10 11 12 OP31 OP36 OP33.10 8(1)(b) 18(2)(a) 10(1) met) 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. (Timescale of 24/03/06 not met) 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, preferred bedtimes). (Timescale of 09/03/06 not met) The registered person to provide CSCI, Eashing office, with a detailed improvement plan, with timescales, setting out how the home is to achieve 50 of care workers qualified to NVQ level 2 in care. The registered person must supply a copy of the Code of Conduct and Practise, set by the General Social Care Council (GSCC), to all staff. The manager must submit a registered manager application to the CSCI, Eashing office. The registered person must fully implement one-on-one formal supervision with all staff. The registered person must submit, to the CSCI, Eashing office, an improvement (action) plan, setting out exactly how requirements 1-11 will be met in full. The plan must include DS0000017599.V297224.R01.S.doc 31/07/06 30/06/06 31/07/06 31/07/06 31/07/06 31/07/06 30/06/06 Collingwood Grange Nursing Home Version 5.2 Page 28 specific timescales for completion of each requirement. 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 OP12.3 Good Practice Recommendations It is recommended that service users’ interests are recorded and they are given opportunities for stimulation through leisure and recreational activities, inside and outside the home, which suits their needs, preferences and capacities. Particular consideration is given to people with dementia and other cognitive impairments, those with visual, hearing or dual sensory impairments or those with physical disabilities. 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. (Brought forward from report of 26/01/06) It is recommended that the quality assurance system is expanded to include seeking the views of stakeholders in the community (e.g GPs, chiropodists, care managers and other health and social care professionals). 2. OP18 3 OP33.7 Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 29 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. Extracts may not be used or reproduced without the express permission of CSCI Collingwood Grange Nursing Home DS0000017599.V297224.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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