Inspection on 01/11/06 for Eckling Grange

This inspection was carried out on 1st November 2006.

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

Eckling Grange 13/02/09

Eckling Grange 03/11/05

Eckling Grange 30/06/05

Eckling Grange 15/03/05

Eckling Grange 10/01/05

Eckling Grange 25/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Eckling Grange Norwich Road Dereham Norfolk NR20 3BB Lead Inspector Maggie Prettyman Key Unannounced 1st November 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 Eckling Grange DS0000027267.V318379.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. Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eckling Grange Address Norwich Road Dereham Norfolk NR20 3BB 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) 01362 692520 01362 690278 eckling.grange5@btopenworld.com Eckling Grange Limited Mrs Irene Launchbury Mr Peter Baldwin Care Home 65 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (19), Old age, not falling within any other of places category (45) Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One (1) service user, named in the Commissions records, who is under 65 and diagnosed with dementia. 3rd November 2005 Date of last inspection Brief Description of the Service: Eckling Grange is a large, two storey, Christian care home providing personal care and accommodation for up to sixty-five older people and is sited on the outskirts of the town of East Dereham. The service comprises of a large period house with extensions and has a complex of sheltered housing bungalows sited in the grounds that are not part of this registration. The home has two passenger lifts to the first floor, sixty bedrooms, thirty of which have en suite facilities, fifty-five are single rooms and a further five rooms that are registered as double rooms and made available to married couples, if required, or as single rooms. The home has communal toilet and bathroom facilities on each floor and service users have communal use of a large dining room, two dining areas, two large lounges, five sitting rooms and a conservatory. The home stands in it’s own grounds, the gardens are well maintained and there is parking to the front and the back of the premises. The service has a management committee with overall responsibility for the home. The range of fees is £311 - £425 per week. Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out using information from previous inspections, information from the providers, the residents and their relatives as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the home and current judgements for each outcome group. What the service does well: What has improved since the last inspection? The home is working towards improving information available to prospective service users and is updating its website. The medication system is being improved, with photographs of service users being included in drugs records. Building works are taking place to improve facilities at the home. A system of supervision of staff has been implemented. Records of social activities are now maintained. Work continues toward NVQ qualification for more staff. Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 6 What they could do better: Some requirements and good practice recommendations have been made at the end of this report as follows; Requirements; • • • The home is to write and implement a thorough recruitment and vetting procedure Notifiable incidents must be reported to the Commission without delay The report of the quality assurance survey must be written and provided to service users and the Commission Good Practice Recommendations • • • • • • • • • Service user records should be kept individually and not recorded in other records such as handover books The recording of non administration of drugs should improve Notice boards promoting activities should be in place and accessible to all service users including those with dementia care needs The home should investigate what changes some service users would like to see in their diet, particularly at teatime. The home should investigate ways of making its comments and complaints procedures accessible to service users with dementia care needs Adult protection training should be updated The home should continue to work toward NVQ targets All accidents, incidents, and occurrences should be regularly audited. The good start made in supervision of staff should be maintained, with consideration given to including ancillary and support staff in this process. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Eckling Grange DS0000027267.V318379.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 Eckling Grange DS0000027267.V318379.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 and 6 Quality in this outcome area is good. The home is currently updating the information available to prospective service users. A comprehensive needs assessment takes place prior to admission. Trial periods are always given before residents become permanent. Respite care enables people to maintain their independence This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user guide and statement of purpose are clear and detailed. The home recognises that they could be more accessible in form and are working on a website including a virtual tour of the home to help people make informed decisions about the home. Information on service users files demonstrates that the competent and experienced manager visits prospective service users to discuss their needs in Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 9 detail prior to admission. This process is supported by information given by social workers if the referral is not a private one. Service users always come to the home on a four-week trial basis. Service users confirmed that they or their family had the opportunity to visit prior to their admission. Respite care is offered on an informal basis by the home. Staff confirmed that people staying for such short breaks are encouraged to maintain their independence whenever possible. Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. An individual plan of care is in place for all service users. Service users health care needs are fully met A safe system of medication operates within the home. Service users are treated with respect and their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of service user plans demonstrated detailed information and clear and up to date records of care. New sheets have been included to record activities undertaken. Care plans were seen to be regularly reviewed. Examination of other records such as handover books demonstrated that at times records are not always kept in service user individual records. It is recommended that the practice of duplicating information in this way cease. Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 11 Separate health care records are kept for each service user. Weights and blood pressure are regularly monitored and recorded. Work to provide specific support to people with dementia care needs takes place. A comment card from a regularly visiting GP described the care given by the home as “exemplary” The home has its own designed system of medication. Individual photo cards to identify service users had been prepared and were in the process of being inserted into medical records. Records showed that the reasons why drugs are not administered are not kept consistently. It is recommended that the recording of non-administered drugs be improved. Observation of care delivery, discussions with service users and pre inspection questionnaires demonstrate that service users are treated with the utmost respect at all times. Service users can have telephones in their rooms, letters are received unopened, and clothes are clearly labelled and carefully kept. Rooms are private and individual spaces. Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Service users find that the home meets their lifestyle expectations and preferences. Service users maintain relationships with their family, friends and community. Service users exercise choice and control in their lives. Food is professionally prepared and wholesome, but some service users would like more variety in the menu This judgement has been made using available evidence including a visit to this service. EVIDENCE: This home has a Christian ethos, and its service users greatly value the spiritual support that is offered. Religious observance is regular and accessible. A variety of other activities take place. The homes practice of taking detailed life histories of service users enables them to offer activities of interest to people who have dementia care needs. A record of activities is kept both individually and as a group. It is recommended that notice boards detailing upcoming activities and regular events be used to promote Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 13 events. These should be accessible to people with dementia care needs where appropriate. Discussions with service users demonstrated that friends and family can visit freely. A relative said that they always feel welcome and supported by the home. A variety of external organisations come to the home to provide activities and entertainment. Service users described outings to the coast and theatre as well as local short walks which have been greatly enjoyed. Service users describe being able to exercise choice and control in their daily lives. Rooms are personalised and individual possessions are treated with care. Life history records enable care staff to respond to likes, dislikes and wishes for service users with dementia care needs. A clean, well-run kitchen provides a wholesome diet. Staff were observed and interviewed and showed an understanding of and commitment to providing good food. Many service users are delighted with the diet. Some commented in pre inspection questionnaires as well as on the day of inspection that they would like a bit more variety, particularly for food served in the afternoon. A copy of “Highlight of the Day” and information about MUST nutritional screening were left in the home by the inspector. It is recommended that the home investigate further what changes some service users would like to see in their diet. Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Complaints about the service are taken seriously and acted upon. Planned updated adult protection training should take place This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with service users confirmed that the home responds well to requests for change or complaints about the service. The dialogue between the management of the home and service users is open and frank. Service users felt that they could speak their mind. The commission has received two criticisms of the home. The home has responded on both occasions positively and resolved issues raised on these occasions. With the move to dementia care, the home may wish to consider ways of making its complaints process accessible to people with dementia care needs. It is recommended that the home consider alternative ways of making complaints for service users with dementia care needs. The homes Care Manager has identified a shortfall in updated Adult Protection training and has purchased appropriate training material to deliver updated training to all staff. It is recommended that this training be completed as a matter of priority. Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is good. Service users live in a safe well-maintained environment. Service users rooms are safe, comfortable and personalised. The home is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises demonstrated that the home is clean, well maintained and tidy. Building work is being undertaken to improve two rooms and office accommodation. This has been undertaken with minimum disruption to service users. Rooms providing accommodation for service users with dementia care needs have been decorated in bright attractive colours, with each door marked individually with a motif of interest to the service user. Personal possessions Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 16 are very much in evidence in all rooms. Service users were observed sitting peacefully in their rooms, often studying religious texts, with call buttons directly to hand if they wish to call upon staff. The call system had been serviced the previous week. Service users interviewed confirmed that their rooms are very much personal and private space. The home was observed to be homely, clean pleasant and hygienic. A purpose built laundry room is spacious and well equipped. Industrial machines ensure correct washing of garments. Nametapes were seen in all garments. Care and attention to care of these items is taken. Sluices were found to be clean and tidy. Cleaning materials are appropriately stored in locked cupboards unless in use Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30 Quality in this outcome area is good. The home is still working towards its NVQ targets. The home needs to ensure that all staff are adequately vetted. Staff are trained and competent to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Difficulties with consistency of service from NVQ training providers have caused the home to fall behind target fro NVQ qualification. It is recommended that the home continues to work toward NVQ training for its staff. Examination of staff files demonstrated that staff recruited by the home do not always have as thorough vetting as is recommended by the CSCI document “In safe Hands” A copy was left with the home by the inspector. It is required that the home writes and implements a comprehensive recruitment procedure in line with this document. Examination of staff files from a recruitment agency showed that validation of copy references, identification and CRB clearance for overseas staff is not provided. Examination of records and discussion with managers demonstrated that an ongoing programme of training takes place. Great effort has been made to improve the language skills of staff for whom English is not their first language. Service users felt that all staff can communicate with them and show a desire to listen and understand. Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 18 Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 Quality in this outcome area is good The home continues to be run by a competent management team. A quality assurance survey has been conducted but the report is not yet written. A system of supervision has been implemented. The health, safety and welfare of staff and service users are protected This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care manager has submitted her Registered Managers’ award portfolio. Both managers in the home are very experienced and competent to do their jobs. The home has not been submitting regular documentation of notifiable Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 20 incidents to the Commission. It is required that notifiable incidents are reported to the Commission as required by the Care Standards. A quality assurance survey has taken place, but a report is yet to be written. It is required that the report of the quality survey is completed. Examination of a variety of record systems demonstrated that audits would benefit the home by identifying possible patterns and trends that could be prevented or need further investigation. It is recommended that audits of record systems take place regularly. Examination of records demonstrated that a system of supervision has been implemented by the home. Managers are working hard to meet the requirements of the care standards in this respect. It is recommended that the good start made in offering supervision to staff is continued, and that this be expanded to include non-care staff. Statutory training is in place in the form of in house training packages. Equipment records demonstrate regular servicing by competent providers. Accidents and injuries are recorded and reported. Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 21 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 3 X 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 X 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 3 Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 22 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 OP29 Regulation 19 sch.2 Requirement It is a requirement that the home writes and implements recruitment and vetting procedure that meets the requirements of the standards in line with “Safe and Sound”. It is a requirement that agency staff references, CRB checks and qualifications are validated by the supplying agency. All notifiable incidents must be reported to the Commission without delay The results of the quality survey must be compiled into a report and supplied to the Commission and service users. Timescale for action 01/12/06 2. OP29 19 sch. 2 01/12/06 3. 4. OP31 OP33 37 24 01/12/06 01/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 23 1. OP28 It is recommended that the encouragement to staff continues to bring the number of NVQ qualified staff in line with the standard up to the level of 50 Records about service users should be maintained in their care records only and not duplicated into other records and logbooks. The recording of reasons why drugs are not administered should be improved. Notice boards detailing regular and special activities should be used. Such boards should be accessible to people with dementia care needs where appropriate. Using “Highlight of the Day”, and in consultation with service users, the home should investigate what changes it can make to its menu to increase variety, particularly at teatime. The home should investigate making its comments, compliments and complaints system accessible to people with dementia care needs. The planned update of adult protection training should take place without delay Regular audits of accidents, incidents and occurrences should take place to identify times, situations and areas of risk to service users. The good start made in supervision should be maintained, with consideration given to extending this system to ancillary and support staff. 2. 3. 4. 5. OP7 OP9 OP12 OP15 6. 7. 8. 9. OP16 OP18 OP33 OP36 Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Eckling Grange DS0000027267.V318379.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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