Inspection on 28/02/07 for Enderby Grange

This inspection was carried out on 28th February 2007.

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

Enderby Grange 08/01/09

Enderby Grange 30/06/05

Enderby Grange 15/04/05

Enderby Grange 05/10/04

Enderby Grange 27/04/04

Enderby Grange 09/03/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Enderby Grange Sparsis Garden Enderby Leicestershire LE19 2BQ Lead Inspector Andrew Sales Key Unannounced Inspection 28th February 2007 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 Enderby Grange DS0000039581.V323886.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. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Enderby Grange Address Sparsis Garden Enderby Leicestershire LE19 2BQ 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) 0116 2752555 0116 2753555 A.L.A. Care Limited Theresa Gasiorowski Care Home 40 Category(ies) of Dementia - over 65 years of age (11), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (40), Physical disability over 65 years of age (6) Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 11 persons to be admitted into the home who fall within the category DE(E) when 11 persons who fall within this category, or this category combined with the MD/E category, are already accommodated in the home. No more than 10 persons to be admitted into the home who fall within the category MD(E) when 10 persons who fall within this category, or this category combined with DE(E), 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. To be able to admit the named person as identified in variation application V25717 dated 17/10/05. 30th June 2005 2. 3. 4. Date of last inspection 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 wheelchair-accessible landscaped gardens and is close to local shops and bus routes. The fees per week range from £400-420. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by A.J.Sales on 28 February 2007. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive, through review of their records, discussion with them and care staff. The inspector also spoke with two other residents and two members of staff. The inspector spent part of the day with the deputy manager discussing policies, procedures and records. What the service does well: What has improved since the last inspection? There were no requirements made at the last inspection and the manager was not present to discuss any improvements or new initiatives. Outcomes for residents are good and the home continues to provide good standards of care. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Enderby Grange DS0000039581.V323886.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 Enderby Grange DS0000039581.V323886.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): 3,4,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are fully assessed prior to moving into Enderby Grange and the residents are confident that the home is able to meet their needs. EVIDENCE: We looked at three care plans. There are paper copies maintained and also all the information relating to the assessment of care is stored on a computer system. The deputy manager informed us that all staff have access to this system. Staff said it is very useful as they can update records instantly, plan reviews and find out what people need quickly. All the plans looked at were very detailed and enabled staff to find out exactly what residents needed and what their preferences were prior to meeting them. Staff said they are made fully aware of keeping records confidential. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 9 We spoke with three residents. They all feel that the service is well coordinated, they are kept well informed and have access to information, help and advice. They also said the staff were polite and very helpful, this was also supported by observations made throughout the inspection. The staff spoken with, demonstrated a sound understanding of the needs of older people and a thorough commitment to their role. They described in detail the assessment and review process, the benefits of good management support and the comprehensive training on offer. Residents told us that they felt the home’s support staff were well trained and ‘excellent’ in their approach. The induction program and training schedule was observed and this will help to ensure that staff are able to meet the needs of residents admitted. Residents told us that the staff are well trained and felt they were in competent hands. The staff commented that the induction to the homes procedures and following training equipped them to provide a good standard of care. The home does not provide intermediate care. Enderby Grange DS0000039581.V323886.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): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are fully assessed with careful consideration to their abilities and preferences. This results in their personal, social and healthcare needs being met. EVIDENCE: We looked at three care plans. These are very well developed and contain detailed action plans for support staff. The computer records also hold details of medication and medication history, along with daily records. These can provide a usefull audit trail, should anyone wish to track changes or deterioration in an individuals healthcare. The inspector spoke with three of these residents who were able to describe what they were supported with and how the staff approached this. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 11 There was evidence that support plans are reviewed by team leaders and key support staff on a regular basis. We observed risk assessments in relation to maintaining independence and risks for all areas of daily living. Staff who spoke with us demonstrated a good understanding of the care planning process and the management of risk. Resident’s plans contain details of each individual’s health care needs, including tissue viability and continence risk assessments. There is evidence that people have been appropriately referred to health care professionals. Care plans viewed, contained records of visits by district nurses, General Practitioners and other professionals. Healthcare professionals were observed visiting on the day. We looked at four staff training records which showed that medication training was provided for staff responsible for the administration of medication. The homes medication administration systems have been well maintained. There is a policy and procedures for receiving, recording, storing, handling, administering and disposing of medicines. The home is registered with the local pharmacist and support and advice is obtained as and when needed. We observed medication records and noted evidence of medication reviews and updates. Three residents told us that the staff understand their needs well. We observed good practice with regard to infection control. Staff carry small clip-on 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. All the feedback we received from residents suggests that the staff are courteous and understanding when supporting them with any task, whether personal care or practical tasks and that the standards overall were ‘excellent’. Some residents were keen to point out that staff would always do extra tasks when asked, but were always mindful of their independence. We observed care staff throughout the day undertaking a variety of support tasks with a professional and courteous manner. Staff commented that they felt the home promoted the independence of residents consistently, throughout the induction, training programs and policies and practices. Enderby Grange DS0000039581.V323886.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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel they retain much of their independence after moving into the home. Resident’s maintain contact with family and friends. A range of activities are provided, which support the leisure and recreational interests of residents. Residents enjoy the food cooked at the home which offers both choice and variety. EVIDENCE: We observed how the care planning process enables each individual to express their preferences. For example, of how support is to be given and how social stimulation is to be offered. The care plans observed showed records of consultation as to what residents might like to do on a daily basis and throughout the year. All of the residents spoken with, said they were happy with the level of activities within the home and outside. Resident’s commented that the Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 13 philosophy of the home and the attitude of the staff enabled them to make choices and felt they were generally well respected. They also felt that staff were always willing to sit and talk with them when they had time away from essential duties. The staff reported that they encourage residents to participate in events and outings. Planned trips and events are organised within the home. We saw notices in communal areas and in resident’s rooms with details of forthcoming events. On the day we observed a craft class in progress with eight residents participating. One resident, who recently came to live at Enderby Grange said, “I really miss my own home, but you can’t fault this place.” The staff we spoke with, were well aware of residents individual preferences and respect residents choice on occasions where they chose not to participate in events. The home employs a cook, a cook/kitchen assistant, and a part-time cook who prepares the teas. We observed meals being prepared and served. This was well organised and unhurried. We saw that many residents had breakfast trays taken to their rooms. The deputy manager explained that residents can choose to eat where and when they wish to. Residents told us that the food in the home is good and well presented. We saw that a selection of meals are available throughout the day. A daily menu board is displayed to ensure residents have the opportunity to choose from the variety of meals available. There are a number of residents with diabetes and/or diet specific needs, which are catered for at the home. All the dining tables were well presented, with cutlery and napkins together with condiments. Residents told us that this practise is normal at the home and that the dining experience is pleasant. The inspector spoke with the catering staff. It was clear they ensure that the kitchen and food preparation areas are hygienic and maintained to a safe standard. Enderby Grange DS0000039581.V323886.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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are safeguarded by the homes complaints and adult protection procedures. EVIDENCE: We observed an appropriate complaints policy and procedure. We looked at records, which are held on a central register. These are well maintained and few complaints are received. Residents told us they would raise concerns with the manager or staff, if they felt the need to. We saw an appropriate Whistle Blowing Policy and a policy detailing Adult Protection Procedures. The homes policies and procedures for responding to suspicion or evidence of abuse, or neglect, are satisfactory. The home has comprehensive policies regarding resident’s money and financial affairs. Three staff told us they had received training in adult protection issues and were fully aware of their responsibilities to safeguard older people. We also saw certificates for this training on staff files. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 15 Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 16 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): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Enderby Grange is well maintained and furnished, providing residents with a homely and spacious environment. EVIDENCE: We looked at all of the communal areas and found them to be well furnished and maintained. Five residents told us how impressed they were with the homes décor and furnishings. One person also said the home is ‘calming and relaxing’. We looked at bathrooms, bedrooms and communal areas including lounges and the kitchen. These are all well kept, clean and free from any odours.. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 17 We looked at two bedrooms, which were well presented and personalised with resident’s personal possessions including photographs and ornaments. Each room viewed was well decorated and very clean. Resident’s who wish to, have their own telephones and all are able to keep their own furniture in their rooms to make them more personalised and homely. Residents spoken with stated they liked their rooms and they were comfortable. The home has a lift to the first floor. Enderby Grange provides its residents with specialist equipment to meet their needs, which includes grab rails in the bathrooms, hoist and other lifting aids and adapted toilet facilities. Some of these were observed in use and staff were able to describe how they supported residents with this equipment. The laundry area viewed was well organised and clean. The laundry facilities included appropriate equipment. We spoke with domestic staff who described cleaning and maintenance schedules. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 18 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): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are normally safeguarded by the homes recruitment and training procedures, but two pre-employment checks have been overlooked, which potentially could place people at risk. EVIDENCE: We observed a large number of care, senior, domestic and kitchen staff on duty. The rotas showed us that this is normal practice and is sufficient to meet the current needs and numbers of residents. Residents said they never had to wait long for support and that it was timely and flexible. We looked at four staff files. They contained all relevant recruitment documents and were very well maintained. Interviews which take place are recorded and kept on file. All of the personnel files that were examined revealed that thorough pre-employment checks are normally carried out. Staff told us that all these recruitment procedures had taken place. However two staff files had Criminal Records Bureau (CRB) checks that had been conducted by previous employers. New employees are required to have a Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 19 new check conducted each time they start employment at the home to ensure residents are suitably protected. The staff explained their roles and how each member of staff operated within the structure. There are different levels for staff to progress to, with increased responsibility, which provides a positive career path should one wish to develop their skills. The manager, it was described, provides clear direction and support to enable staff to develop their potential. We observed training certificates on staff files. These covered all mandatory training subjects and other training subjects relating to the different support needs of older people. Staff spoken with, commented positively on the training and support offered. Two members of staff told us they felt supported by the senior staff. The staff files contained records of meetings. Evidence from staff confirmed that they received regular supervision and meetings with their colleagues. Larger group staff meetings are held on a regular basis. Evidence of staff appraisals was observed on staff files. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 20 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): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Enderby Grange is run in the best interest of the residents. The health, safety and welfare of residents and staff is promoted. EVIDENCE: All of the residents spoken with said they felt the home was well run and the management team and staff were always on hand for support and advice. Staff we spoke with, confirmed that they felt supported by the manager senior staff and that they are approachable to discuss any issues. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 21 All of the residents spoken with, stated that they felt they were consulted about day to day issues. We saw evidence of reviews, residents meetings and consultation carried out with individual residents. A relevant policy with regards to the safe keeping of resident’s personal allowances is in place and followed. Running records of resident’s cash accounts are stored on the computer system, but we were unable to check cash amounts on this occasion, as the deputy manager did not have access. It is recommended that delegated staff should have access in the future so residents have access to their money. The staff who spoke with the inspector, confirmed they receive regular supervision and attend regular team meetings. We observed staff files, which contained records of supervision and appraisal. Staff spoken with also supported this process. All of the staff files showed us that staff have undertaken training in mandatory health and safety subjects. Staff spoken with, were aware of health and safety procedures and commented positively on the training provided. Risk assessments were observed on individual files and are in place for the building and individual residents. Records for Health and Safety monitoring and the servicing of systems and appliances were inspected on this occasion and were found to be up to date. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 23 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 (1,b) Requirement Ensure the two identified members of staff have Enhanced Criminal Records Bureau checks conducted by the homes own registered body, following an immediate P.O.V.A first check, to ensure the safety of residents. Timescale for action 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP8 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 homes 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 preDS0000039581.V323886.R01.S.doc Version 5.2 Page 24 2. OP16 3. 4. OP30 OP38 Enderby Grange inspection report he were asked to complete by CSCI and in this way provide details of the homes arrangements for health and safety. Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Enderby Grange DS0000039581.V323886.R01.S.doc Version 5.2 Page 26 - 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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