Inspection on 27/09/05 for Coombe Grange Residential Home

This inspection was carried out on 27th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Coombe Grange Residential Home 02/09/09

Coombe Grange Residential Home 28/01/08

Coombe Grange Residential Home 01/08/06

Coombe Grange Residential Home 25/05/05

Coombe Grange Residential Home 22/11/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Coombe Grange Residential Home Coombe Lane Sway Lymington Hampshire SO41 6BP Lead Inspector Keith Hopkins Unannounced Inspection 27th September 2005 13:15 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 Coombe Grange Residential Home DS0000061686.V249400.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. Coombe Grange Residential Home DS0000061686.V249400.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Coombe Grange Residential Home Address Coombe Lane Sway Lymington Hampshire SO41 6BP 01202 767776 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) Coombe Grange Limited Mrs Valerie Anne Clarke Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (40), Old age, not falling within any other category (40) Coombe Grange Residential Home DS0000061686.V249400.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2005 Brief Description of the Service: Coombe Grange is set in a rural location on the edge of the village of Sway with limited access to local amenities. It provides residential care for up to 40 elderly residents, some of whom may have dementia. The home is on ground, first and second floors and there is a lift between ground and first floors. There are a variety of aids and adaptations to allow residents to move about more independently. Twenty four of the bedrooms are single, and eight are doubles. There are two communal toilets and a bathroom on the ground floor, and one toilet two bathrooms and two showers on the first floor. There are large gardens around the building. Coombe Grange Residential Home DS0000061686.V249400.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Three and three quarter hours were spent visiting the home, during which time the opportunity was taken to look around the home, view records and policies and to talk to the manager, deputy manager and administrator. The inspector also spoke privately with two members of staff. Most of the residents were seen to be using the communal areas and several were spoken with briefly in the main lounge. Three residents were spoken with at greater length in private and the inspector was also able to speak with two visitors to the home. What the service does well: What has improved since the last inspection? Residents’ comfort has been enhanced through the redecoration of some communal areas and the recarpeting of some bedrooms. Record keeping regarding dispensed medication is improved, being accurate at the time of the inspection. Coombe Grange Residential Home DS0000061686.V249400.R01.S.doc Version 5.0 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. Coombe Grange Residential Home DS0000061686.V249400.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 Coombe Grange Residential Home DS0000061686.V249400.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): Outcomes for this group of standards were not inspected on this occasion. EVIDENCE: Coombe Grange Residential Home DS0000061686.V249400.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): Outcomes for this group of standards were not inspected on this occasion. EVIDENCE: Coombe Grange Residential Home DS0000061686.V249400.R01.S.doc Version 5.0 Page 10 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. Residents enjoy varied lifestyles and undertake activities of their choice. The provision of a wide range of opportunities for stimulation, through sound links with the local community, is appreciated by residents. EVIDENCE: At the time of the inspection several residents were enjoying a ‘music and movement’ session in the main lounge, and others were relaxing in quieter areas around the building. A communion service had been held that morning and the inspector was informed that there was a regular evening church service each month. One resident confirmed her continuing interest in religious affairs. Nine residents had taken a trip around the New Forest followed by a ‘cream tea’ the previous week. One resident said that she knew that a singer was visiting the home the following week and that she ‘would probably go’. Other residents confirmed the extent to which there were choices over everyday activities, saying, for example, that they could have breakfast in bed if they wanted to. Coombe Grange Residential Home DS0000061686.V249400.R01.S.doc Version 5.0 Page 11 Two visitors to the home were spoken with in private saying that there were ‘lots of entertainments’, that they were ‘happy with the care’ and that their relative was ‘well looked after’. Visitors are welcomed at any time but asked to avoid mealtimes if possible. The home’s menus were examined and were varied, the inspector being informed that other than one diabetic diet, there was currently no need for the preparation of any other special diets. Coombe Grange Residential Home DS0000061686.V249400.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. The home has a suitable complaints procedure, which residents are aware of and feel able to use. Residents are protected through an adult protection policy and procedure known and understood by staff. EVIDENCE: The home has a complaints policy and procedure, copies of which are provided to residents on their admission to the home. All three residents spoken with privately said that they knew how to complain if they needed to, but all said that they had ‘no complaints’. The home’s complaints book was examined and an instance noted where a resident had complained about the noise from someone else’s television. This had been resolved through the purchase and use of cordless headphones. There have been no complaints for the home to deal with since the most recent inspection. The home also has a policy and procedure relating to adult protection. Staff have been trained in this and when interviewed confirmed their understanding of what to do in the case of suspected abuse. Coombe Grange Residential Home DS0000061686.V249400.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): 19, 23 and 26. Residents enjoy comfortable private and communal surroundings which could be enhanced through some redecoration and ‘freshening up’ in some areas. Residents’ safety is compromised by the lack of adequate ventilation in food preparation areas. EVIDENCE: The home is well maintained and suited to residents’ needs. It is decorated and furnished to a standard that creates a homely ambience although some of the communal areas appear a little ‘worn’. Three residents’ bedrooms were inspected and were adequately furnished and looked homely, as residents had been able to bring items of their own furniture and possessions with them. The inspector noted the report following a recent environmental health officer’s visit, which asked the home to improve ventilation in the food preparation area. Coombe Grange Residential Home DS0000061686.V249400.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. Staff at the home are well trained, are employed through a robust recruitment procedure, and are deployed in sufficient numbers to meet residents’ needs. EVIDENCE: Staff were observed during the inspection to be providing assistance to residents in a calm and unhurried manner. Further observation during the inspection confirmed that staff were able to spend time socialising and talking with residents. The staff rota indicated there to be seven care staff on duty each morning and four on duty each afternoon and evening. These staff were supported by management and domestic staff, including a cook. There are two ‘waking’ members of staff on duty each night, and a further person ‘sleeping in’ in case of emergency. Care staff members spoken with said that they were busier between 5pm and 8pm and at breakfast time but that there were generally enough of them on duty. One resident said that staff ‘always come in an emergency’ and that ‘they’re all wonderful’. Two staff records examined indicated a recruitment process, which included the obtaining of written references, and of Criminal Records Bureau disclosures being obtained. There had been a variety of courses undertaken by staff, including for example, food hygiene, manual handling and infection control. Coombe Grange Residential Home DS0000061686.V249400.R01.S.doc Version 5.0 Page 15 The inspector was informed by the manager that four staff members had been trained to NVQ Level 2 and a further three to NVQ Level 3. Coombe Grange Residential Home DS0000061686.V249400.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, 33, 35, and 38. The home is well managed with residents having a clear and accessible means of influencing policy and practice. Financial interests are safeguarded and residents’ welfare is promoted through sound policies and procedures. EVIDENCE: The manager has a considerable number of years experience in a senior capacity, has recently completed the Registered Managers Award and is currently undertaking specialist training in dementia. There are clear lines of accountability within the home and to external senior company staff. The inspector saw questionnaires completed by relatives of residents, as a part of the home’s quality assurance programme, which confirmed satisfaction with the services offered. Residents spoken with also all commented on how nice the home was, and are also consulted formally regarding the services offered. Coombe Grange Residential Home DS0000061686.V249400.R01.S.doc Version 5.0 Page 17 The home’s administrator confirmed that there was no involvement by the home in residents’ financial matters, and one resident confirmed that clear information had been made available regarding fees prior to her entering the home. No immediately obvious hazards to health and safety were observed by the inspector during the inspection and staff commented that in general terms the building was a nice environment in which to work. A sample of policies and records required by regulation were inspected and were in order and up to date. This included the home’s fire and accident books. A fire drill had been undertaken on 22nd September 2005 and fire training on 14th September 2005. Coombe Grange Residential Home DS0000061686.V249400.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 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 X X 2 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 Coombe Grange Residential Home DS0000061686.V249400.R01.S.doc Version 5.0 Page 19 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. 1 Standard OP2626 Regulation 12 Requirement The home must provide improved ventilation in food preparation areas. Timescale for action 31/12/05 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 OP1919 Good Practice Recommendations The home should continue its programme of refurbishment and redecoration. Coombe Grange Residential Home DS0000061686.V249400.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Coombe Grange Residential Home DS0000061686.V249400.R01.S.doc Version 5.0 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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