Inspection on 07/02/06 for Littleport Grange

This inspection was carried out on 7th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Littleport Grange 16/06/09

Littleport Grange 16/06/08

Littleport Grange 18/12/07

Littleport Grange 13/09/07

Littleport Grange 15/01/07

Littleport Grange 28/06/05

Littleport Grange 17/01/05

Littleport Grange 07/06/04

Littleport Grange 24/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Littleport Grange Grange Lane, Ely Road Littleport Ely Cambridgeshire CB6 1HW Lead Inspector Mrs Alison Hilton Unannounced Inspection 7th February 2006 08:30 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 Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 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. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Littleport Grange Address Grange Lane, Ely Road Littleport Ely Cambridgeshire CB6 1HW 01353 861329 01353 862878 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) Dove Care Homes Limited Catherine Ann Mary Doswell Care Home 75 Category(ies) of Old age, not falling within any other category registration, with number (75), Physical disability over 65 years of age of places (75) Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Old age not falling within any other category (OP) - 75 Physical Disability over 65 years of age (PD(E)) - 75 Date of last inspection 28th June 2005 Brief Description of the Service: Littleport Grange is registered as a care home with nursing for up to 75 older people. Although the home is registered with 75 beds some double rooms have been made into singles, and other policy changes have been made to reduce this number to 66. The home is considering changing the registered number of beds available, although it could still accommodate that number. Accommodation is provided in a large detached property set in attractive and well-maintained grounds on the edge of the town of Littleport. There are local amenities within walking distance and the city of Ely is a short drive away. The house is on three floors made accessible by two lifts and stairs. There are a number of lounges and dining rooms available to residents. There are 58 single and four large double bedrooms, most with en-suite facilities. There are registered nurses on duty at all times as well as day care and night care assistants, administrators, cooks, housekeepers, bed makers, laundry workers, maintenance man, gardener and full time activities co-ordinator. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on Tuesday 7th February 2006 between the hours of 08:30 and 12:45. The manager was present for the inspection. The inspector toured the building; spoke to residents and staff, observed practice, and looked at resident and staff files and other documents. An immediate requirement was left in relation to Regulation 19 (Standard 29) and the home having POVA First checks or Enhanced Criminal Record Checks (CRB’s) regarding staff, prior to their commencement of employment at the home. What the service does well: What has improved since the last inspection? What they could do better: All staff should have a POVA First check or Criminal Record Check (CRB) completed and on file, before they start work at the home. This would include those who visit regularly such as the hairdresser. The home is considering making an application to change the registered number of available residential places from 75 to 66. The call bell in one room was not working and it was discussed with the manager and head nurse if there was any way they could be checked daily. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 6 There was a consensus that the care staff could test each one as they went round in the morning when assisting people to get up. The home should provide training in Protection of Vulnerable adults to all staff not just nurses and carers. 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. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 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 Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 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 the following standard(s): 3,6 The homes admission procedure ensures that there is a proper pre-admission assessment completed to ensure needs can be met. EVIDENCE: The manager said that the home no longer had beds that were solely used for intermediate care. On the resident files seen there was evidence that their needs had been appropriately assessed. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 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 the following standard(s): 7,10 The home ensures that staff are clear about the care necessary for each resident with understandable and comprehensive plans of care. There are arrangements in place that ensure each resident receives input, from appropriate and relevant professionals, to ensure their health needs are being met. Personal care is given sensitively and in private and residents are given choices (as far as practicable) in areas such as when they would like to get up or when they would like a bath that day. EVIDENCE: There was evidence on file that comprehensive plans of care are completed and reviewed. Some residents spoken to were unsure if they had taken part in the process but they had signed to confirm their agreement of the care plan. Residents said they were well treated by staff and provided with any necessary equipment such as specialist beds. Staff were observed knocking doors before entering and when speaking to residents they were chatty and friendly whilst Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 10 treating them with respect and courtesy. Residents were offered choices, and when spoken to after the staff had left, residents said this was part of the care they received not just because the inspector was there. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 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 the following standard(s): 12,13 The range of activities the co-ordinator organises is wide ensuring residents interests and preferences are considered. Residents are encouraged to make choices about their lives and remain as independent as possible. EVIDENCE: The home continues to have exceptional provision in relation to the activities co-ordinator. She is active in providing appropriate activities and encouraging residents to participate. Some residents spoken to said they did not choose to take part in activities. Although some said the activities were not what they wanted they could not think of anything they would like to do that was not provided. Several said they were visited regularly by family and friends and sometimes went out with them. Visitors are always made welcome at the home and this was seen during the inspection. Residents had many personal items in their rooms, but furniture and electrical equipment must meet the relevant safety standards before being brought into the home. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 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 the following standard(s): 18 All staff at the home need to complete Protection of Vulnerable Adult (POVA) training to ensure the residents are protected from abuse. EVIDENCE: At the last inspection staff were completing the Protection of Vulnerable Adults training but there were only two places available on each course. It was suggested that the manager might be able to get the trainer to come to the home because of the large numbers of staff involved. On further discussion at this inspection the manager said that she was going to attend the three-day POVA trainer course, which would allow her to provide in house training. 18 staff have completed the POVA training. It was discussed with the manager that all staff, not just nurses and carers, need to complete the training. The manager is aware that staff should have completed the POVA training within 6 months of employment at the home. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 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 the following standard(s): 19,20,22,23,24,25,26 The home is suitable to meet the needs of the residents. The home is clean and hygienic and there were no unpleasant odours. EVIDENCE: The home continues to provide suitable accommodation with several dining rooms and sitting rooms for all service users. The main seating area is light and airy. The décor throughout the building is well maintained and clean. The toilets seen during the inspection had paper towels and liquid soap available, but in one there was a hand towel, which could increase the risk of cross infection. The manager said it would be removed immediately. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 14 The residents’ rooms seen during the inspection were seen to contain personal items of furniture, pictures, ornaments and photographs. The rooms were clean and homely. There was also equipment such as wheelchairs and hoists in rooms where there was a need. Those spoken to during the inspection said that any equipment they needed had been provided by the home and they were very happy with it. The home was clean, hygienic and free from offensive odour in the areas and rooms seen during the inspection. The home has separate sluicing facilities and washing machines that meet disinfection standards. The large grounds were tidy on the day of inspection, but staff and residents said that until the weather improved they were not going outside. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29,30 The homes recruitment procedures had not been followed for two staff, whose files were seen during the inspection, therefore the home could not ensure that unsuitable staff had not been employed. An immediate requirement was made in relation to this standard. EVIDENCE: Although the two staff files contained the necessary paperwork the POVA First checks had only been completed after the staff members had commenced employment. It was also noted that the hairdresser (who visits the home several times a week) had not completed any checks. Staff spoken to displayed a good knowledge and understanding of various areas of their work. They all said that the statutory training had been provided, although some were still waiting for POVA training. This has been discussed at Standard 18. Staff said that they felt the manager would be open to any requests for training that they made. Staff who cleaned the home had completed the necessary training and were very knowledgeable about infection control and how to avoid cross infection. They knew who had MRSA and how to deal with it. Care staff were also very clear about infection control and were able to inform the inspector, in detail, of the procedures they followed. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,36 The home is being managed effectively, and there is leadership, guidance and direction for staff to ensure the residents receive a consistent quality of care. Formal supervision is taking place to ensure the welfare of residents through information about policies, procedures and best practice guidance. EVIDENCE: The manager is registered with the commission and is a qualified nurse and has a management qualification confirmed by TOPSS as being equivalent to NVQ 4. The home does not handle any resident’s finances. Supervision of staff does take place both formally and informally. Informal chats re individual issues in relation to residents for example are not always Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 17 documented. Formal supervision is documented and at the last inspection it was recommended that the supervisor and supervisee sign the notes, to ensure that both parties agree on what was discussed and the outcomes of that discussion. This is now being done, which meets the recommendation from that inspection. A check of some of the documents required to be kept in the home was made and they were in order. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 18 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 3 X 3 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 X X Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES 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 OP18 Regulation 18 Requirement The registered person must ensure that staff receive training appropriate to their work. This is in relation to training in the Protection of Vulnerable Adults within 6 months of their employment commencing. The registered person must not employ a person to work at the care home unless the appropriate checks have been completed. (This was in relation to POVA First checks being completed after commencement of employment, and in relation to checks being necessary for the hairdresser.) An immediate requirement was left at the time of inspection. Timescale for action 01/04/06 2 OP29 19 07/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 20 No. Refer to Standard Good Practice Recommendations Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Littleport Grange DS0000024311.V272292.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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