Inspection on 30/06/05 for Foxleigh Grove Nursing Home

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 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

Foxleigh Grove Nursing Home 23/08/06

Foxleigh Grove Nursing Home 13/12/05

Foxleigh Grove Nursing Home 18/01/05

Foxleigh Grove Nursing Home 26/08/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE FOXLEIGH GROVE NURSING HOME Forest Green Road Holyport Maidenhead SL6 3LQ Lead Inspector Rhian Williams-Flew Unannounced 30 June 2005, 10:00 am 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. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Foxleigh Grove Nursing Home Address Forest Green Road, Holyport, Maidenhead, Berks, SL6 3LQ 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) 01628 673332 Mr and Mrs Aram Mr M A R Aram Ms G J Aram; Mr S Aram Mrs Elizabeth Moxon Mrs Adrianne Plant Care Home (CRH) 39 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The numbers of persons for whom accommodation is provided at any one time shall not exceed 39. 2. The category of persons to be accommodated shall be that of: Older people, within which up to a maximum number of 5 may be adults with physical disability. 3. Within the 39 there is a variation of conditions of registration for one service user under the category Mental Disorder. This variation remains in place whilst the service user is accommodated in the home. 4. Use of rooms. The two rooms on the first floor in the area previously known as The Coach House are no longer part of the total of registered beds and therefore cannot be used for service users. 5. The room known as Goring situated on the first floor of the home can only be used by service users if a documented risk assessment of their mobility capabilities has been undertaken. Date of last inspection 18 January 2005 Brief Description of the Service: Foxleigh Grove is a care home with nursing. It provides care to older people who do not suffer from a diagnosis of dementia and younger people with physical disabilities. The home is managed by a General Manager, Mr Mark Aram. There are also two Care Managers, Mrs Plant and Mrs Moxon. They share the responsibilities of the Registered Manager position. In addition, they are responsible for the clinical care provided at the home. The home provides its accommodation over two floors which are serviced by a passenger lift. The majority of the rooms available are for single occupancy. The home is situated in the village of Holyport on the outskirts of Maidenhead. It has extensive gardens which are much appreciated by the residents in the home. The train station is approximately 2 miles away. A bus service runs near to the care home. The home also has its own transport which residents can utilise for appointments and visits to the local amenities. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection occurring on a weekday between 1000 hrs and 1530 hrs. The General Manager, Mr Mark Aram was present throughout the inspection. 6 of the residents were spoken with along with 1 relative. 6 members of staff were also spoken with. 7 of the residents (accompanied by a number of staff) were participating in a visit to Blenheim Palace as a planned excursion. This was an excursion of their choice. They were all looking forward to their visit. What the service does well: What has improved since the last inspection? There were no requirements from the previous inspection. This home continues, through their own audit mechanisms, to strive for improvement on their already high standards. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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 FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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) None Not applicable. EVIDENCE: None of these standards were inspected on this occasion. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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) None Not applicable. EVIDENCE: None of these standards were inspected on this occasion. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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 & 15. This home is proactive in maintaining the residents links with the local community and their relatives and friends. It provides an excellent programme of activities and interests for the residents. EVIDENCE: 7 of the residents were participating in an excursion to Blenheim Palace. This was a planned visit of their choice. It is planned that a further 2 events will be held at the same venue for the other residents who have expressed an interest in the excursion. Other excursions and visits have already taken place this year and the others are also planned. The Activities Coordinator along with the General Manager hold regular 3 monthly meetings with the residents to discuss the programme of events they wish to pursue. From these discussions a monthly activities schedule is published and copies are provided for each resident. The activities programme is extremely varied and from the residents spoken with, it is very much appreciated. The Activities Coordinator tries to ensure that there are activities and events that will be of interest to all of the residents. For some residents she provides one-to-one interaction. The residents spoken with were very impressed by her level of skill and how she always finds something interesting for them to enjoy. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 Page 11 Several of the residents spoken with commented how welcomed their relatives and friends are made to feel when they visit the home. A number of the residents continue to have links with local organisations that they still visit and participate in. Some of the residents spoke of the privacy they are afforded at the home. This was not just with regard to providing personal care tasks but also in their wish to have their own company in the privacy of their own room. The Chef was spoken with and the kitchens visited during the inspection. The dining room was visited whilst the residents were eating their mid-day meal. All commented favourably on the food served to them and how much they enjoyed it. Residents said that only one hot meal choice is publicised on the menu but they all said that if they preferred an alternative this was always provided. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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) 16 & 18 This home is responsive to comments and complaints as it always strives to provide the best service and care to the residents. It also ensures that all guidance on the protection of vulnerable adults is adhered to. EVIDENCE: There has been one complaint since the previous inspection, which was dealt with in a timely fashion by the General Manager. The complaint was upheld and actions have been taken to prevent a recurrence of the highlighted issue. The complainant was satisfied. This home is responsive to comments and complaints made by residents and their relatives and friends. The General Manager assured that the home does have the current interagency guidance on the protection of vulnerable adults and members of staff are familiar with it. The General Manager also ensures that the correct protection of vulnerable adults checks are made on all staff recruited to the home. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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, 20, 22 & 26. This home is clean, well maintained and is furnished and equipped to a very high standard. EVIDENCE: This home is well maintained and provides a safe environment for residents to use. The extensive gardens are well maintained and are well used by the residents and their relatives. A number of residents commented on their appreciation of being able to use the gardens. There are a number of communal spaces in the home, which are accessible to the residents. Some of the service users commented on their appreciation of being able to use different places in the home. Since the previous inspection at least 9 residents have been afforded the provision of overhead tracking hoists in their rooms. The General Manager confirmed that 3 more overhead tracking hoists would be installed in other rooms in the very near future. This provision of service benefits not only the staff but also the residents, as it gives them more autonomy and choice. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 Page 14 The home is kept clean and hygienic. Some of the residents spoken with made specific comment about the cleanliness of the home. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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, 28 & 29 This home is very well staffed to meet the needs of the residents. The recruitment procedures are robust and the home is committed to offering training to staff. EVIDENCE: The home has a full complement of staff to meet the needs of the residents who live in the home. On the day the inspection there were 2 qualified members of staff on duty alongside 7 carers, to meet the needs of 29 residents. A full complement of staff had also accompanied the residents who had gone on the excursion. Of the residents spoken with all were very complimentary about the attention the staff provide. They commented on the occasional delay in staff answering call bells although, they did appreciate that these events were unusual. The home continues to show commitment to offering NVQ training to staff. A few more staff are being encouraged to take up the qualification. 2 members of staff have their NVQ 2 qualification; 3 members of staff are completing it and 2 are due to commence the qualification in September 2005. The General Manager hopes to achieve the standard of 50 of staff achieving the qualification by 2005. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 Page 16 The recruitment records of the most recently recruited member of staff were reviewed and were found to contain all the necessary documentation as required by the regulations. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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) 32, 33, 36, 37 & 38. This is a well managed home with a strong management team. Staff members feel well supported and residents feel the home is managed in an open and inclusive way. EVIDENCE: From the comments of the members of staff and the residents who were spoken with, all felt that the management team are open, positive and inclusive. Staff members felt very well supported both professionally and personally and the residents were quite clear whom they would approach if they had any particular comments or concerns. The General Manager is preparing to review the quality monitoring systems that are in place. From the comments of the residents they felt that they would be listened to. A sample of the policies and procedures were reviewed and were found to be up-to-date. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 Page 18 The supervision records of staff were not reviewed but members of staff were able to confirm that supervision is held regularly and they find it helpful. Selections of records were reviewed to ensure safe working practices are followed. The Health and Safety Executive Inspector has also recently visited the home. The General Manager has provided an action plan to the report from this Inspector in a timely fashion and addressed all the actions required. Following a visit to the laundry area it was noted that members of staff are practising an unsafe technique to remove boxes off high shelves. This was drawn to the attention of the General Manager who gave his assurance that alternative arrangements would be made to enable staff to reach this area whilst limiting risks. FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION 4 3 x 4 x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 4 3 x x 3 3 2 FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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 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 28 Good Practice Recommendations To continue to encourage care staff to consider undertaking a National Vocational Qualification (NVQ) to ensure that 50 of the care staff have achieved this qualification by 2005. The General Manager provides a safer alternative arrangement for the laundry staff to reach high shelving and to implement a risk assessment. 2. 38 FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Berks RG7 4SA 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 FOXLEIGH GROVE NURSING HOME H52-H01-S10985-Foxleigh Grove-V222594300605-Stage 4.doc Version 1.30 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. 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