Inspection on 30/06/05 for Eckling Grange

This inspection was carried out on 30th June 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

Eckling Grange 13/02/09

Eckling Grange 01/11/06

Eckling Grange 03/11/05

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 Ruth Hannent Unannounced 30th June 2005 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. Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Eckling Grange Address Norwich Road, Dereham, Norfolk, NR20 3BB 01362 692520 01362 690278 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) Eckling Grange Limited Mrs Irene Launchbury Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (65) of places Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 65 older people of either sex may be accomodated Date of last inspection 15th March 2005 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 dinning 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. Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over five hours with the two Managers. Some records were inspected. A meal was taken with the residents. Six residents were spoken to. A tour of the communal areas took place with two bedrooms viewed. 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. Eckling Grange I55 s27267 ecklinggrange v236647 300605 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 Eckling Grange I55 s27267 ecklinggrange v236647 300605 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) EVIDENCE: These standards were not inspected on this occasion. Eckling Grange I55 s27267 ecklinggrange v236647 300605 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, 9 and 10 Care plans are written to meet the individual needs of the residents. The procedure of administering medication needs to be reviewed to ensure clear practice happens to safeguard the residents. The dignity, respect and privacy is upheld in the best interest of the residents. EVIDENCE: Three care plans were looked at. Details included the original assessment, the care plan with reviews recorded, dated and signed, risk assessments, room assessment and accident records. Two residents were spoken to of files that were seen who were able to give a full picture of the care they receive. On discussion it was clear that each person was happy with the times they were assisted such as the morning drink to start the day to the care they received throughout the day and the time they choose to retire. The medication at lunchtime was observed and it was noted that medication was placed on the dining table in pots and left on the table for the person to take when they wished. The staff member signed the recording sheet to say the person had swallowed the medication but, this process, had not been Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 9 witnessed by that staff member. This is not safe practise and the Home needs to review its policy and procedure on the administration of medication. (Requirement) The five residents spoken to in the dining room were happy to discuss the way the Home helps them preserve their dignity and privacy. Each one has their own room that they can lock if they so wish. The staff knock on the door before entering their rooms and speak in a courteous manner. It was noted when walking the building that staff were speaking in a appropriate manner to residents. Eckling Grange I55 s27267 ecklinggrange v236647 300605 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) 12,13,14 and 15 With the Christian ethos, people are offered the lifestyle they expect and have their recreational interests met in a way that matches their needs. Relatives, friends and the local community are encouraged to be involved in the life of Eckling grange to ensure contact is maintained. With regular Home meetings and regular reviews of care plans residents can voice their choices over their lives. The meal taken was wholesome, enjoyed by the residents and eaten in pleasant surroundings. EVIDENCE: The Home offers a Christian environment which the people who wish to live there understand and are themselves Christians. Their interests and expectations are met by the home with religious services and meetings held regularly. The residents spoken to talked of the visitors that are welcomed into the home and how they are encouraged to be involved as much as possible. On speaking to one visitor it was evident that she enjoys her visits and feels welcome. She Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 11 spoke of the support her relative receives and that she also attends the events planned throughout the year when possible. One gentleman was attending the Norfolk show that week and was able to request a packed lunch. Another gentleman had two visitors who were able to take lunch in the dining room with him. Many activities and theme events are taking place within the Home. Resident meet together regularly (three monthly) to discuss what and how they would like to see events taking place. Minutes of a meeting held with residents on April 8th showed the inclusion of ideas that were being discussed with the possibility of guest speakers coming in to talk on hobbies and interests. The weekend after the inspection there is a large strawberry tea for all residents, families and friends. This was creating a conversation around the meal table at lunchtime. One lady told of her involvement in the knitting and craftwork she does for the goods to be sent to places like Zambia and these were seen on display in the hallway. The lunchtime meal was taken with the residents in a pleasant room with grace being offered by a resident. There was the offer of cottage pie or cheese and onion flan for the main course with fruit and custard or yoghurt for dessert. The residents all said they could not fault the meals and that choice was always available. Some people eat in the dining room, some in their rooms and some in a smaller area. The meal was hot, looked appetising with the vegetables served in dishes for people to help themselves. After the meal everyone had the opportunity of a cup of tea or coffee. One gentleman explained how the meal of the day is discussed at breakfast so people can choose what they would like and the menu was also up on a wipe board to remind everyone. Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 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 standard(s) EVIDENCE: These standards were not inspected on this occasion. Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 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 standard(s) 19 and 26 The Home is regularly working towards maintaining and improving the environment to ensure it is a safe place to live in. The Home was very clean, bright, well decorated and with no unpleasant odours EVIDENCE: The Home has regular plans to ensure the building and surroundings are maintained. Recent removal of trees that are unsafe has taken place with plans to replant more trees. The gardens and hedges cover a large area and were seen as well tended. The kitchen has recently had new cookers, the boilers have been changed to gas, and work has begun on the pipe work of the corroded pipes. This has caused a time delay of ensuring all the radiators are covered and was unforeseen but the work will be completed by the end of August. On walking around the building it was noted how clean the Home was. There were no unpleasant odours and the laundry is sited outside the building where Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 14 appropriate containers were in place for various items of clothing and linen. The Home has just written a more comprehensive policy on infection control and the Manager is ensuring the staff will be trained and practise the correct procedure. Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 15 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) 27,29 and 30 The staff on the rota were sufficient in numbers and the levels of skills appeared appropriate throughout to meet the needs of the residents. The two files seen held the correct paperwork to ensure staff are recruited who are appropriate to do the job. The home plans training over the twelve months to ensure staff are able to do their work in a competent manner. EVIDENCE: The rota’s for the monthly cycle were displayed on the wall with heads of care, supervisors and care staff covering all shifts. All the job roles are colour coordinated to help identify any short falls. The manager explained that all shifts are covered unless it is last minute sickness, which sometimes is difficult to cover. Staff are only allowed to assist with personal care if they are 18 or over. Under 18’s are able to do tasks such as bed making, helping with meals or assist with activities. This was noted when a person was making enquires about a care vacancy and clear direction was given about the job details by the Manager. Two personnel files were seen and contained application form, contact – offer of employment, two references and the cleared CRB check. A copy of the staff handbook was seen that had recently been updated and is issued to new staff used in staff meetings as information sharing. Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 16 The Home has, this year, had 24 staff complete first aid in the workplace, 20 covered the food hygiene course and planned is the fire safety training. The Home has also introduced two new policies one on infection control and one on risk assessment in the heat. All the staff discuss these policies in meetings and then sign the form to say they have read and understood what the policy is about. (Seen). Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 17 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) 31,33 and 36 The Manager is competent and able to carry out her duties fully. The NVQ qualification, once achieved will enhance that ability. The Home has a good method for measuring quality and moving forward with ideas that are in the best interests of the residents. Staff have started to have supervision. This is beginning in a way that will ensure staff gain an understanding and benefit from the one to one meetings. EVIDENCE: The Manager has been in post for many years and is trying to achieve her NVQ4 by the end of 2005. There have been various problems in getting the course completed since the start (Jan 2004), which has caused delays in moving forward. Some of these problems have now been cleared and the award will hopefully be achieved at the end of December. With two Managers Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 18 taking different areas of responsibility the Home is managed with the skills of both parties. During the week following the inspection quality assurance comment forms were being distributed to:Relatives and friends on the Saturday, residents on the Monday and staff on the Wednesday with a return date of August 1st. The information is then analysed and feedback sent to all parties involved. This type of survey is carried out by the Home every two years and actions required from the points raised are discussed in residents meetings. Supervision is a new concept for Eckling Grange and to ensure the staff have a full understanding and are able to gain value from such a session an introduction into these one to one’s are taking place with a personnel advisor and Manager. Three supervision sessions for all staff are planned for this year with plans for sessions every two months from 2006. Records of two staff members supervision notes were seen and were dated 9/03/05 and 29/06/05. The person assisting with all personnel issues was able to explain the supervision introduction in the Home and how it was being cascaded to staff. Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 19 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x 3 x x 3 x x Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 20 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) Timescale for action The Registered Manager must Immediate ensure that staff follow safe and administration of medication with ongoing a more detailed policy in place for the medication procedures. 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 Good Practice Recommendations Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 3rd Floor, Cavell House St Crispins Road Norwich NR3 3BN 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 Eckling Grange I55 s27267 ecklinggrange v236647 300605 stage 4.doc Version 1.40 Page 22 - 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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