Inspection on 13/07/05 for East Dean Grange

This inspection was carried out on 13th July 2005.

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 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

East Dean Grange 21/07/08

East Dean Grange 01/08/07

East Dean Grange 14/09/06

East Dean Grange 01/12/05

East Dean Grange 22/11/04

East Dean Grange 04/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE East Dean Grange Lower Street East Dean East Sussex BN20 0DE Lead Inspector James Houston Unannounced 13 July 2005 10:00 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 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. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service East Dean Grange Address Lower Street East Dean East Sussex BN20 0DE 01323 422411 01323 422412 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Limited William Simpson Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (OP), 33 of places East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is 33 (thirty three) 2. The care home can provide personal care to older people aged 65 (sixty five) years or over on admission Date of last inspection 22 November 2004 Brief Description of the Service: Care First Care Homes Ltd, a subsidiary of BUPA homes owns East Dean Grange. It is registered to provide care for 33 older people. The home offers hotel style accomodation in a large detached country house situated in the village of East Dean approximately 4 miles from Eastbourne. The home has an indoor swimming pool on site, a drinks bar and designated parking areas in the extensive and well-maintained grounds. The home has a shaft lift and chair lift that provide access to most areas except for three rooms in the old building. All bedrooms are en-suite and decorated to a high standard. In addition to the en -suite faciliites thre is a communal shower and the baths have an electric seat to improve access. The dining area is on two levels and there are additional lounge areas. Included in the fees is a taxi service to Eastbourne twice a week. The home is close to the church, village hall and public house. Residents are able to participate in local events and groups should they wish to. The home has dedicated activities organisers. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the thirteenth of July 2005. Before the inspection papers held by the Commission for Social Care Inspection were read and those standards of the standards to be assessed prepared. The inspection in the home took 7.25 hours. A tour was made of most of the premises. A variety of records including four care plans and policies and procedures were read. The inspector met nine residents, a relative, four staff and the manager. There were twenty-three residents accommodated on the day of the inspection. What the service does well: What has improved since the last inspection? 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. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 7 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 standard(s) 3 and 5. The home fully assesses prospective new residents. Residents are encouraged to visit the home before admission to assist them in the decision about whether or not to enter the home. EVIDENCE: Records inspected showed that the home conducts its own a detailed assessment of the care needs of prospective residents. The manager or a senior carer completes these. Where a resident chooses not to give information on a topic it is recommended that a brief statement be added to the needs assessment. Residents said that they and/or a relative or representative had visited the home before they made the decision to come in. A prospective resident and their family were making such a visit to the home during the inspection and were seen by the manager. Intermediate care is not offered in the home. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 8 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 standard(s) 7,8,9 and 11. Care plans are well drawn up but should be reviewed more regularly. The healthcare needs of residents are well met. Drug administration systems are generally good, but medicines administration records should be reviewed. The home offers good care to residents who are dying. EVIDENCE: The care plans inspected were found to be comprehensive. Risk assessments were found to be well documented. Residents sign to acknowledge their involvement in drawing up care plans. The home aims to have plans reviewed monthly but in some plans sampled this had not been achieved. Staff said that the provider is going to provide training in care planning shortly for all staff. The home has a key worker system. Residents said that their health care needs are well met. Residents said that they have access to a local GP. The manager said that relationships with the local community nurses are good. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 9 The home has visits from a local pharmacist to inspect its systems and the most recent report shown to the inspector and reporting on a visit a month ago said that there were no issues. The home holds controlled medication and two staff sign for its administration. Three residents self-medicate, and have suitable risk assessments regarding their ability to do so. A resident who self medicates was aware of the need to ensure that the drugs in her room are securely kept. Medication administration records inspected showed some gaps. Staff said that they have had suitable training, and records inspected confirmed this. The home has a suitable policy on the action to be taken in the event of a resident dying. A relative said that they had been very impressed by how the home had cared for their late relative during their last illness. Some of the home’s care plans inspected do not contain sufficient detail of the wishes of residents as to arrangements to be made in the event of their death. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 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 standard(s) 12 and 13. Social activities are well managed and provide variation and interest for people living in the home. Visitors are made welcome. EVIDENCE: Two staff share lead responsibility for arranging activities. Residents said that they feel free to participate or not in this programme that includes quizzesone was taking place during the inspection- scrabble, and music and movement. The home has its own indoor swimming pool. A resident said she was going out that morning to the local market held nearby, and some residents go out to the local church and many said that they go out with their families. The home offers occasional outings. A weekly programme of events for the current week was on display in the home, and a newsletter is published from time to time. Residents said that their visitors are always made welcome in the home and are offered hospitality. A visitor said she was welcomed in the home. Staff said that this is an important aspect of their role. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 16 and 18. The home has suitable arrangements to deal with complaints made to it. The home’s procedures, processes and training for staff are designed to protect residents in the event of any abuse or allegation of abuse. EVIDENCE: The home has a suitable complaints procedure. During the inspection the manager rang his provider to arrange to be supplied with a leaflet giving the correct details regarding the Commission for Social Care Inspection. Residents said that they are aware of the procedure. Records inspected showed that the home has received no complaints since the last inspection, and none have been made to the Commission for Social Care Inspection concerning the running of the home. The home has a suitable adult protection policy and records inspected showed that staff are given a copy of the home’s whistle-blowing policy on appointment and sign to acknowledge its receipt. Staff said that they have had training in adult protection matters and records inspected confirmed this. Since the last inspection the adult protection procedures have not been invoked regarding any resident in the home. Staff on appointment receive a copy of the home’s policy on receiving gifts and gratuities on appointment and sign to acknowledge its receipt. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19,20,24 and 26. The home provides accommodation to a good standard. Communal areas and bedrooms are well presented, providing excellent accommodation. Laundry facilities are suitable. EVIDENCE: East Dean Grange is a converted premise that has been extended and adapted to its present use and offers a very attractive environment with character. The home has a programme of routine maintenance and its own handyman. The grounds of the home are safe, tidy and accessible and provide a very pleasant area, which residents sitting out said they were enjoying in the summer sunshine. There are three areas of communal space- a main lounge with a small bar, a music room and a sun lounge. The home also has an attractive restaurant that is on two levels. All offer a high standard of accommodation. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 13 Residents said that they like their rooms. All bedrooms are en-suite and residents said that they have been encouraged to bring in their own furniture into their rooms. They appreciate this facility. Inventories are kept of their possessions and these were available for inspection. Residents have locks to their rooms and said that they are able to choose if they lock their rooms. Some said they choose to do so. The home was found to be clean and tidy throughout. The home has a large and well-equipped laundry sited well away from food preparation areas. Residents said that the laundry service works well for them. A staff member confirmed that there is a suitable hot wash cycle. The home has infection policies and staff said that they have had relevant training East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. A competent staff team meets residents’ needs. Staff holds the recommended qualifications. The home has robust recruitment processes. The home has a commitment to staff training. EVIDENCE: A staff rota was available for inspection. Residents and staff said that there are sufficient staff on duty to meet the needs of residents. Residents said that when they use the call system to summon assistance staff respond promptly and helpfully. Residents and staff said that staff turnover is not high. The manager and staff said that agency staff are not used. The manager said that he and senior staff from the provider are on call to staff. The manager said that 10 out of 16 care staff hold NVQ 2, i.e. in excess of the recommended level of 50 . One these holds NVQ 3 and another is about to complete it. The manager said that four staff are about to commence NVQ level 2. Recruitment records examined showed that the information required by the regulations is held. Staff said that they are given copies of the General Social Care Council Code of conduct and records inspected confirmed this. Staff receive statements of terms and conditions of employment. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 15 Records inspected showed that staff receive suitable induction and foundation training. Records showed a variety of recent training in such matters as care skills, dementia, and drug administration. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,35,36,37 and 38. The home has an open and positive atmosphere. Residents and their representatives in general control their own finances. Formal supervision should be given more regularly. Records are generally well kept. The health and safety of residents and staff are protected. EVIDENCE: The home holds regular staff and residents meetings and the minutes of these were made available to the inspector. Residents said that they feel confident to contribute at these meetings and to approach the manager and staff at any time if they have got any issues to raise. Staff said that they are able to raise ideas with the manager to improve the services for residents. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 17 Most residents administer their own finances, some with the help of their families or solicitors. The home holds records of monies held on behalf of several residents and these were found to be well maintained. The home does not usually keep valuables for residents, but the facility to do so exists, and appropriate records are kept. The home gives regular supervision to care staff, but records inspected showed that this is not at the recommended frequency of at least six times per year. Records were found to be generally well kept, except where referred to elsewhere in this report. Residents said that they were aware that they could access their records but that to date they had not chosen to do so. A linen store door marked to be kept locked shut was found to be unlocked. The manager arranged for this to be rectified during the inspection. Records inspected showed that staff receive regular training in fire safety, and that call points are regularly tested, and fire-fighting equipment regularly serviced. Staff said that they have received training in load management and records inspected confirmed this. First aid training for the whole staff group has been arranged. Certificates inspected showed that arrangements are made for the inspection of the gas and electricity systems. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 x x x 3 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 Standard No 16 17 18 Score 3 x 3 x x 3 x 3 2 3 3 East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 19 NO Are there any outstanding requirements from the last inspection? 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 9 Regulation 13(2) Requirement Ensure medication is administered correctly Timescale for action Immediate. 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. 2. 3. 4. Refer to Standard 3 7 21 36 Good Practice Recommendations Where residents do not wish to give details add this to care assessments. Review care plans monthly. Ensure care plans contain details of residents wishes regarding arrangements to be made after their death. Provide formal supervision for care staff at least six times a year. East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex BN21 4QT 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 East Dean Grange H59-H10 S21090 East Dean Grange V230747 130705 Stage 4.doc Version 1.40 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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