Inspection on 08/01/09 for Enderby Grange

This inspection was carried out on 8th January 2009.

CSCI found this care home to be providing an Excellent service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Enderby Grange 28/02/07

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

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Bramble Lodge

Parkmanor Residential Home

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London Road Neurological and Specialist Care Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 08/06/2011.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Enderby Grange Sparsis Garden Enderby Leicestershire LE19 2BQ     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Kim Cowley     Date: 0 8 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 27 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Enderby Grange Sparsis Garden Enderby Leicestershire LE19 2BQ 01162752555 01162753555 enderby@ala-care.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Theresa Gasiorowski Type of registration: Number of places registered: A.L.A. Care Limited care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: 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 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 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. Care Homes for Older People Page 4 of 27 Over 65 11 10 40 6 0 0 0 0 Date of last inspection Brief description of the care home 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 four 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 range from £400- £420 per week. Futher information about the home is available from the Manager or our website csci.gsi.gov.uk Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. This was a key inspection that included a visit to the home and inspection planning. Prior to the visit, we (throughout the report the use of we indicates the Commission for Social Care Inspection) spent half a day reviewing information relating to the home. During the course of the inspection, which lasted six hours, we checked the key standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means we looked at the care provided to three residents living at the home by meeting them; talking with the staff who support their care; checking records relating to their health and welfare; and viewing their Care Homes for Older People Page 6 of 27 personal accommodation as well as communal living areas. Other issues relating to the running of the home, including health and safety and management issues, were examined. We also talked to eight further residents, one relative, the Manager, Deputy, administrator, three carers, the cook, a District Nurse, and a visiting tutor. One resident, three relatives and five staff surveys were returned to CSCI prior to the inspection. All respondents made many positive comments about the home. Some of these are quoted throughout this report. What the care home does well: What has improved since the last inspection? What they could do better: One relative has asked for more films to be shown in the homes cinema (in the dining room), and another has asked for occasional trips out for residents. Consideration should be given to these suggestions. A notice should be put up reminding residents and visitors that they can use the chapel Care Homes for Older People Page 8 of 27 at any time and just to need to ask a member of staff for the key. The staff rota should be reviewed and staff members consulted to ensure there are occasions when staff are given time to spend with individual residents. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 27 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Quality in this outcome area is good. Residents needs are assessed prior to admission to ensure the home is suitable for them. This judgement has been made using available evidence including a visit to this service. (Standards 3 was inspected.) Standard 6 was not inspected, as this home does not provide intermediate care. Evidence: People who are interested in coming to Enderby Grange are invited to visit prior to making a decision. The Manager or another senior member of staff assesses all prospective residents in their own homes, in hospital, or during a visit to the home. The assessment process helps to ensure the home is suitable for residents who are considering living there. Care Homes for Older People Page 11 of 27 Evidence: One resident talked to us about his experience of choosing the home. He told us, My family looked at a few homes and thought this was the best one of the lot. I came to see it and thought it looked like a hotel so I decided to move in. Records relating to three recent admissions were examined. All were of a good standard and the views of relatives, and assessments carried out by health and social services staff, had been taken into account. Standard 6 was not inspected, as this home does not provide intermediate care. Care Homes for Older People Page 12 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Quality in this outcome area is excellent. Staff in the home, and in the wider community, meet residents health and personal care needs. This judgement has been made using available evidence including a visit to this service. (Standards 7, 8, 9, and 10 were inspected.) Evidence: All residents have care plans, which set out how their health, personal and social needs are to be met. Residents and their relatives, where appropriate, are consulted when care plans are written and sign to say they are in agreement with them. Those care plans inspected were well-written and gave clear instructions to staff about how best to meet residents needs. Case tracked residents talked to us about their preferences with regard to personal care, likes/dislikes, and interests, and it was positive to note that this information was Care Homes for Older People Page 13 of 27 Evidence: in their care plans. One relative we talked to said, Everythings good here and the care is excellent. Care plans also showed that some residents had made progress since moving into Enderby Grange. For example, one resident we case tracked who had been a wheelchair user, was now walking independently. Since the last inspection the Gold Standards Framework has been introduced to help ensure that residents receive the best possible care at the end of their lives. Sixteen staff members have completed the relevant training. Records showed that residents have access to a full range of health care treatment including input from GPs, district nurses, CPNs, chiropodists, dentists, and opticians. We talked to a District Nurse who was visiting residents on the day of inspection. She told us that the home was always clean and the staff friendly and professional. Staff who administer medication have completed a Safe Handling of Medication course which gives them the skills they need to look after medication effectively. Medication is stored securely and administered in line with GPs instructions. It was observed during the inspection that staff treat residents with respect and help to maintain their dignity by providing care discreetly and sensitively. Care Homes for Older People Page 14 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Quality in this outcome area is good. Residents social and cultural needs are identified and met. This judgement has been made using available evidence including a visit to this service. (Standards 12, 13, 14, and 15 were inspected.) Evidence: Since the last inspection the Activities Programme has improved, following consultation with the residents. Activities are advertised on a noticeboard in the entrance to the home. They include arts and crafts twice a week, visiting entertainers, exercises classes, and clothes parties. Photos of residents taking part in activities and events are kept in album as examples of the type of things residents can do while living in the home. Two relatives who filled in surveys prior to the inspection suggested improvements to the activities programme. The home has a cinema in the dining room and one asked for more films to be shown. Another asked for the residents to go on occasional trips out. Consideration should be given to these suggestions. Care Homes for Older People Page 15 of 27 Evidence: The home has its own chapel. One resident said he thought he couldnt use it as it was locked. This was discussed with the Manager who said it was kept locked because, on occasions confused residents had gone in an moved things around. She said residents and visitors are welcome to use the chapel at anytime and all they have to do is get the key from a member of staff. It is suggested that a notice is put up reminding residents and visitors of this. Visitors are welcome at the home at any time and are invited to stay for meals if they wish. Drinks and snacks are available at all times from vending machines in the foyer. There is a Family Room which can be used for visits if desired. A small library of mainly large print books is kept there and staff help residents choose their books on request. A relative told us, The staff always give me a lovely welcome and Ive got to know some of them very well. Records showed that a wholesome and varied diet is provided. Lunch consisted of sweet and sour pork with rice, or fish in parsley sauce, with mashed potatoes and vegetables. Dessert was pineapple flan and cream. One relative told us, Theres always a choice at every meal. Another said, You can stay for dinner any time and the foods very good. Since the last inspection, at the request of residents, small gravy boats have been purchased for those who want to pour their own gravy, and pasta dishes have been added to the menu. Mealtime are flexible where necessary. For example one resident was going out on the evening of the inspection so staff arranged for him to have an early tea in his room. Drinks and snacks are available on request and one resident told us, If I want a coffee in the middle of the night I can go to the kitchen and get one. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Quality in this outcome area is good. Residents and their representatives are encouraged to talk to staff about any concerns they might have. Staff know how to safeguard residents. This judgement has been made using available evidence including a visit to this service. (Standards 16 and 18 were inspected.) Evidence: The residents we talked to said they would have no difficulty in speaking out if there was anything they were unhappy about. One told us, If I had a complaint the Manager would sort it out, Ive no doubt about that. And a relative said, If there were any problems Id tell the Manager. A poster in the reception area explains the complaints procedure to residents and visitors, should they wish to use it. The Manager told us that anyone who complains will be listened to, taken seriously, and their concerns acted upon. She said that both positive comments and constructive criticism were always welcome as it helped to ensure the home continued to run well. There has been one complaint since the last inspection. This was investigated internally and not proven. Care Homes for Older People Page 17 of 27 Evidence: The home has a safeguarding procedure in place which explains what staff should do if they have concerns about the way a resident is being treated. Staff are trained in safeguarding and know how to recognise the signs of abuse and what to do if they have concerns about a residents well-being. Care Homes for Older People Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Quality in this outcome area is excellent. Residents live in an environment that is safe, comfortable, and well maintained. This judgement has been made using available evidence including a visit to this service. (Standards 19 and 26 were inspected.) Evidence: Enderby Grange was purpose-built and provides spacious accommodation over two floors. All areas of the home are wheelchair-accessible and there is a passenger lift to the first floor. There is a good range of communal areas including four lounges (two of which are quiet rooms), a sun lounge, hairdressing salon, visitors lounge, chapel, and treatment room. Meals are served in a large dining room which overlooks the secure landscaped gardens. All bedrooms are ensuite and have telephone points and nurse call systems. Some have extra facilities, for example their own showers, or patio doors leading out to the gardens. We looked at five bedrooms during the inspection and all were personalised and individual to the residents who occupied them. We toured the home and saw that it was well decorated and maintained to a high Care Homes for Older People Page 19 of 27 Evidence: standard. All the areas we inspected were clean and tidy. One resident we spoke to told us, The cleaners do one heck of a good job. Im impressed. A relative said, The home is always clean. Its a lovely modern building and the residents all have their own toilets. Care Homes for Older People Page 20 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Quality in this outcome area is good. An established staff team meets residents needs. Relationships between staff and residents are warm and caring. This judgement has been made using available evidence including a visit to this service. (Standards 27, 28, 29, and 30 were inspected.) Evidence: All the staff we met were friendly and helpful and had a good understanding of the needs of the residents they care for. One resident told us, Some of the staff are lovely and it makes you pleased when you know theyre on a shift. A visiting tutor commented, What really stands out about this home is the friendliness of the staff. I have never ever heard them be impatient with a resident. And a relative said, (The staff are) well-trained with a low turnover so residents and relatives get to know them and feel comfortable with them. The rota showed that the home is well-staffed at all times. One resident told us they never had to wait for long if they needed help from the staff. However, in their surveys, three staff members said they would like more time to spend on a one-to-one basis with residents. One said, I would like more time to attend to residents personal Care Homes for Older People Page 21 of 27 Evidence: care, for example doing their hair and nails. It is recommended that the rota is reviewed and staff members consulted to ensure there are occasions when staff are given time to spend with individual residents. Recruitment procedures were discussed with the Manager. She confirmed that all staff are subject to CRB and POVA checks, and references are obtained. Staff files were sampled and had the appropriate documentation in place. This helps to ensure residents are safeguarded. Staff receive good training opportunities. Training courses are ongoing and records showed that staff are encouraged to develop their existing skills and learn new ones. A visiting tutor, who was providing training in Nutrition and Health to staff on the day of inspection, said, This company asks for a lot of training and they ensure their staff do it. Ive got 30 doing the current course. Care Homes for Older People Page 22 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Quality in this outcome area is excellent. Residents live in a home that is safe and well managed. This judgement has been made using available evidence including a visit to this service. (Standards 31, 33, 35, and 38 were inspected.) Evidence: The Manager is well-qualified and experienced. She has an excellent rapport with residents, staff, and visitors and deals promptly with any issues that arise. The residents we talked to spoke highly of her. One said, The Manager understands me like no-one else does. Staff said they found her supportive and hard-working. One staff member told us, The Manager is always around to discuss matters with and regularly compliments staff on their work. Residents are involved in the running of the home in a number of way. Regular Care Homes for Older People Page 23 of 27 Evidence: meetings are held when they are asked for their views. The last one was held in October 2008 and 20 residents attended. Menus were on the agenda and the minutes showed residents playing an active part in choosing the food they would like. Annual quality assurance surveys are sent out to residents and their representative. The Manager and Owner make their mobile phone numbers available to visitors so they can be contacted directly by anyone who wishes to comment on the home. The Manager will look after small amounts of cash for residents on request. Any money held is kept securely with appropriate records in place. Records showed that the Owner and Manager have taken the necessary steps to promote and protect the health, safety, and welfare of residents and staff. Since the last inspection an Environmental Health Officer has inspected the kitchen and awarded it three stars which means it meets good hygiene standards. Care Homes for Older People Page 24 of 27 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 29 19 (1,b) Ensure the two identified 28/02/2007 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. Care Homes for Older People Page 25 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 12 12 Consideration should be given to relatives suggestions for more trips out and film shows for residents. A notice should be displayed reminding residnets and relatives that they can access the chapel at any time by asking a member of staff for the keys. The rota should be reviewed and staff members consulted to ensure there are occasions when staff are given time to spend with individual residents. 3 27 Care Homes for Older People Page 26 of 27 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 27 of 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!