CARE HOMES FOR OLDER PEOPLE
Enderby Grange Sparsis Garden Enderby Leicestershire LE19 2BQ Lead Inspector
Kim Cowley Unannounced 30 June 2005 11:00 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. Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Enderby Grange Address Sparsis Garden Enderby Leicestershire LE19 2BQ 0116 2752555 0116 2752555 None A.L.A. Care Limited 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) Vacant Care Home 40 Category(ies) of DE(E) Dementia - over 65 (10) registration, with number MD(E) Mental Disorder - over 65 (10) of places OP Old age (40) PD(E) Physical Disability - over 65 (6) Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: No more than 10 persons to be admitted into the home who fall within categories MD(E) when 10 persons who fall within this category/combined categories are already accommodated in the home. No more than 10 persons to be admitted into the home who fall within categories DE(E) when 10 persons who fall within this category/combined categories are already accommodated in the home. No more than 6 persons to be admitted into the home who fall within category PD(E) when 6 persons who fall within this category are already accommodated in the home. Date of last inspection 15.04.05 Brief Description of the Service: Enderby Grange is a 40-bedded purpose built residential care home. It caters for older people, some of whom have mental health needs and/or physical disabilities. All bedrooms are single, over 12 sq m, and have ensuite facilities. There are three lounges, a dining room, visitors’ room, chapel, craft room, balcony/roof garden, and conservatory. The home is set in wheelchairaccessible landscaped gardens and is close to local shops and bus routes. Enderby Grange C51 C01 S39581 Enderby Grange V236224 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 that took place on a weekday. The inspector met with eight residents and two relatives, three care staff, and the Responsible Individual. The premises were toured. Care records were examined. Four recommendations were made. What the service does well: What has improved since the last inspection?
Care plans (including risk assessments) have been amended and updated and residents made aware of them. They are regularly reviewed. An improved programme of activities has been devised and implemented and an activities organiser recruited.
Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 Page 6 The Acting Manager and the cooks have reviewed the menus and made some improvements in response to residents’ comments at the last inspection. The Acting Manager has addressed staffing issues raised at the last inspection. Staff hours meet minimum standards and staff attitudes have improved. 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. Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 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 standard(s) 3 All residents undergo a thorough assessement prior to admission and the results of this are recorded. EVIDENCE: The Acting Manager has responsibility for assessing all residents prior to admission. She visits them in hospital or in their own homes to do this. A ‘Residential Inquiry’ form is then completed. This contains basic factual information about residents and a brief summary of their care needs. Once the resident is admitted to the home this form is used as a basis for their care plan. All residents undergo this assessment regardless of whether they are social services or privately funded. Residents’ records were inspected and found to contain satisfactory assessments prior to admission. Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 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 standard(s) 7, 8. 9. 10 Care plans have been substantially improved. Residents’ health, personal and social needs are clearly set out. Care plans for residents with physical disabilities showed an improved awareness of their needs. Staff on duty were knowledgeable about medication administration policies and procedures, although improvements still need to be made to records and storage facilities. EVIDENCE: Since the last inspection all care plans have been amended and updated. A residents’ meeting has been held to ensure all residents are aware of care plans and understand their purpose. Records showed that care plans are reviewed monthly and risk assessments every three months. Care plans for residents with physical disabilities showed an improved awareness of their needs. A ‘Communications Book’ has been started to improve joint working between District Nurses and staff at the home. Staff said this is proving effective.
Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 Page 10 Good practice with regard to infection control was noted. Staff carry small clipon bottles of disinfecting hand wash which they use between residents when carrying out care tasks. Further bottles are kept at central points in the home for staff use. The home’s contract pharmacist last inspected the home’s medication systems on 26.01.05 and found them to be satisfactory. The senior in charge of medication on the day of inspection was knowledgeable about the policies and procedures in place. She said ‘I feel confident that I’ve received proper training in medication administration. However, if there was something I wasn’t sure about I’d ask the manager or the head senior.’ Medication records were inspected and found to be mostly compliant. Two improvements should be made: • • Two staff should always sign when controlled drugs are administered The lock one of the internal drug cupboards should be repaired or replaced The Acting Manager oversees medication administration and keeps records of staff training ion this area. Residents and relatives interviewed said they were satisfied that care needs were being met and all said that residents were treated with respect by staff. Comments included: ‘The staff can’t do enough for you.’ ‘The staff communicate well with each other and with us.’ ‘(One care worker) is particularly good. He’s a nice lad and a lovely carer. If he’s busy he’ll tell you, and then come back to you when he can. And he always does come back.’ Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 Page 11 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, 15 Residents have the opportunity to take part in range of activities. Menus have been improved and residents are satisfied with the food available. EVIDENCE: Since the last inspection an improved programme of activities has been devised and implemented. An activities organiser has been recruited. She works with residents in the craft room every Tuesday and Friday. A ‘Progressive Mobility’ class was being held on the day of inspection. The person in charge said up to 15 residents attend this monthly class. A forthcoming evening of music hall entertainment was advertised on the residents’ notice board, as was a clothes party. Numerous thank you cards and letter from relatives are also displayed. The home employs a cook, a cook/kitchen assistant, and a part-time cook who prepares the teas. At the last inspection some residents expressed concern about the food in the home. In response the Acting Manager and the cooks have reviewed the menus and made some changes in response to residents’ comments. Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 Page 12 Residents’ and relatives’ comments at this inspection indicated that the food has improved and that residents are satisfied with it: ‘My (relative) didn’t eat much when she was at home but she’s eating now.’ ‘Lunch was very nice today. We had Yorkshire Pudding and it was lovely.’ ‘I’ve never had a bad meal here.’ ‘At lunch we get a starter, a main course, and a pudding.’ Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 Page 13 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, 18 The complaints procedure should be amended and made more easily available to residents. Policies and procedures are in place to protect residents from abuse. EVIDENCE: The home’s complaints procedure should be updated to state that complaints can be made to CSCI at any time, complainants do not have to go through the manager of the home first. (The reference to the Complaints Procedure in the Terms and Conditions should also be amended for the same reason.) It is also suggested that the complaints procedure is written in a more ‘user friendly’ style, is displayed in the home, and that staff make residents more aware of it. The home has a written policy called ‘Guidelines for the Prevention of Abuse to Residents’. This document provides information on safeguarding service users and includes information on procedures for passing on concerns to the relevant parties (in accordance with the Public Disclosure Act 1998 and Department of Health Guidance ‘No Secrets’). There is a whistle blowing policy in place, which requires staff to report any concerns they may have to senior staff. Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 Page 14 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) 26 All areas inspected were clean, tidy and fresh. EVIDENCE: These standards were inspected at the last inspection. However the premises were toured and the home was again found to be commendably clean, tidy and fresh. Residents’ comments about the cleanliness of the premises were all positive and included: ‘The cleaners work hard.’ ‘This is a lovely clean home.’ ‘When you go for a walk round the home doesn’t smell.’ Enderby Grange C51 C01 S39581 Enderby Grange V236224 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, 30 Staff hours meet minimum standards. Staff files are in need of improvement as some required information is not in place. All staff undergo a thorough induction. EVIDENCE: At the last inspection concerns were raised about the number of staff hours provided and about the attitude of some members of staff. The Acting Manager has addressed these issues and one member of staff has left. Staff hours have been reviewed and on the day of inspection met minimum standards. When recruiting staff a checklist is used to document the vetting and assessment process. Staff are sent an application pack and asked to come to the home for an interview, bringing with them the necessary documentation. If staff take up a post before they have received Criminal Records Bureau clearance they work under supervision at all times until it arrives. All staff are given contracts, the ALA Care Ltd profile and company structure, health and safety information, and an employee handbook. Staff files were inspected. Four staff were still awaiting clearance from the CRB, although all had signed personal declarations to state they had no criminal convictions. Induction records were, in some cases, incomplete. Not all staff had two references, including one who had no references at all on file
Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 Page 16 despite being employed in the home since December 2005. This is unacceptable. All new staff undertake the TOPSS induction ‘First Steps’ which leads to NVQ Level 2. Records are kept of their progress. Courses in Basic Food Hygiene, Infection Control, Safe Handling of Medication, and Manual Handling are available to staff. Residents’ comments about the staff were positive. One said ‘All the staff are good’, and another commented ‘The staff are very nice and pretty busy.’ Enderby Grange C51 C01 S39581 Enderby Grange V236224 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) 33, 35 The Acting Manager has a good rapport with residents. Effective administrative systems are in place to enable the home to run smoothly. Information relating to health and safety should be supplied to CSCI. EVIDENCE: At present the home has an Acting Manager. She spends some time on the floor as a carer and the rest doing the administrative work that relates to care. All the residents interviewed praised the Acting Manager. One said ‘She’s brilliant.’ Residents’ finances are handled by the residents’ themselves, or their relatives or solicitors. Staff said that if any concerns arise about residents’ access to their own monies social service are informed. Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 Page 18 Standard 38 was not inspected as the Responsible Individual has not yet returned the pre-inspection questionnaire he was asked to complete. This includes an audit of health and safety policies, procedures, and routines within the home. When this is returned it will be checked and a further visit made to the home if necessary. Enderby Grange C51 C01 S39581 Enderby Grange V236224 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3
COMPLAINTS AND PROTECTION x x x x x x x 4 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 3 x 3 x x 3 x 3 x x x Enderby Grange C51 C01 S39581 Enderby Grange V236224 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 Regulation None Requirement Timescale for action 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 8 Good Practice Recommendations Medication records should be improved so that two staff always sign when controlled drugs are administered, and the lock one of the internal drug cupboards should be repaired or replaced. The home’s complaints procedure should be updated to state that complaints can be made to CSCI at any time, complainants do not have to go through the manager of the home first. Staff induction records and files must be improved so that they are complete and all staff have two references on file. The Responsible Individual should return the preinspection report he were asked to complete by CSCI and in this way provide details of the homes arrangements for health and safety. 2. 16 3. 4. 30 38 Enderby Grange C51 C01 S39581 Enderby Grange V236224 300605 STAGE 4.doc Version 1.40 Page 21 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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