Inspection on 07/11/05 for Otterbourne Grange

This inspection was carried out on 7th November 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

Otterbourne Grange 30/01/09

Otterbourne Grange 11/10/06

Otterbourne Grange 09/05/05

Otterbourne Grange 01/09/04

Otterbourne Grange 19/04/04

Otterbourne Grange 19/05/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Otterbourne Grange Pitmore Road Otterbourne Winchester Hampshire SO21 2HZ Lead Inspector Peter J McNeillie Unannounced Inspection 7th November 2005 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 Otterbourne Grange DS0000012155.V265042.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. Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Otterbourne Grange Address Pitmore Road Otterbourne Winchester Hampshire SO21 2HZ 02380 253 519 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) Mr S Hennessy Mrs S Shine Care Home 25 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (25) Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A total of five service users in the category MD(E) and DE(E) may be accommodated at any one time 9th May 2005 Date of last inspection Brief Description of the Service: Otterbourne Grange is a privately owned and managed care registered to accommodate up to twenty-five older people, including up to five with an age related mental health problem, (DE[E] dementia and MD[E] mental disorder. The home, a large Victorian Manor House which is set in five acres of its own accessible grounds and gardens, accommodates residents in nine single and eight double bedrooms, five of which are equipped with en suite toilet facilities. The home is located within easy access e.g. the M3 motorway and urban areas of Chandlers Ford and Eastleigh. The cities of Southampton and Winchester are within thirty minutes travelling time. Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections for 2005/2006. During the inspection which took place between 9:00am and 12:30pm the inspector who was assisted by the registered manager spoke with 14 resident’s, the registered manager, the registered person and staff on duty. Evidence was also gathered from a tour of the building, reading records, care plans, previous inspection reports comments by management/staff, observations and responses to comment cards distributed prior to the inspection by The Commission for Social Care Inspection( C.S.C.I.). What the service does well: What has improved since the last inspection? The previous high standard commented on in previous reports has been maintained for both new and more established residents, including improvements to the physical environment where the entrance hall has been redecorated and new curtains provided. Four bedrooms have been redecorated and re carpeted and a more detailed format for producing nutritional assessments developed. Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 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. Otterbourne Grange DS0000012155.V265042.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 Otterbourne Grange DS0000012155.V265042.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): 1,2 and 3 Prospective residents are issued with information they need to make a choice about living in the home which has a well developed system of assessing and identifying residents needs which ensures residents safety and assessed needs can be met. EVIDENCE: Residents confirmed they had all been made aware of the homes statement of purpose which was available and issued with terms and conditions of residence on admission and a service users guide on admission.. Residents and records confirmed persons were only admitted on the basis of a full and detailed multi disciplinary assessment of need and risk by the manager or other member of the senior staff and a number of other external health care professionals including GPs, geriatricians, continence advisors, Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 9 physiotherapists, occupational therapists and care managers. Apart from verbal confirmations by residents records viewed also confirmed residents or their representatives were consulted and contributed to the assessment process. Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The arrangements for planning care are clear ensuring that the health, personal care and medication needs of residents are met and their privacy and rights respected EVIDENCE: Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 11 All of the residents when spoken with expressed total satisfaction with the care they were receiving and the manner in which it was delivered. They also confirmed they were consulted about the contents of their individual care plan and the assessments on which the plan was based. All were aware they could view their plan at any time. Care plans which were reviewed monthly contained information on how identified needs including any special needs were to be met. Residents confirmed any personal care was given in private, staff always knocked and waited before entering their bedroom, they were able to make/receive telephone calls and receive and converse with visitors in private. Files seen and comments made by staff confirmed consultation with a range of external health care professionals e.g. doctors, district nurses, community psychiatric nurses, geriatricians, and continence advisors take place. Other specialists would be consulted on a needs basis. All resident’s drugs and medicines which are securely stored are administered in accordance with the homes medication policy and procedure including recording the administration and disposal of unwanted drugs records of which were viewed. No residents were self-medicating. Risk assessment and evidence to confirm consultations as who is responsible for the administration of resident’s drugs and medication was available as were records confirming all staff administering drugs and medicines had received training. Staff confirmed residents or their representatives were free to choose their own GP and the source of other personal services eg chiropodists, dentists optician etc and would receive assistance in accessing any service in the community. Any restriction on choice with regard to a GP was outside the control Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The social activities family contacts and the provision of varied and nutritious meals were well managed and reflected service users interests and choices. EVIDENCE: A list of in house and community based activities for the month was displayed in the main lounge. Activities available included scrabble, boat trips, birthday celebrations, reminiscence, walks shopping, music and movement theatre trips and a keyboard entertainer. Records seen confirmed members of staff had attended courses run by Age Concern on games and activities. All of the residents spoken with praised the efforts of the staff for ensuring they were well cared for. Comments such as “its lovely here” ”The best” ”We could not ask for more” “You will not find a better place” are examples of the remarks made. Residents also confirmed they were fully consulted and were able to exercise choice in all aspects of their lives i.e., when to get up and go to bed, mealtimes (meals at a later time would be provided if they were out at usual meal times or chose to get up late). The quality, quantity, and choice of food served came in for particular praise from the residents. A full and varied menu based on individual likes, dislikes and choices produced by a professional cook was available. Since the last inspection nutritional assessments of residents has improved considerably, the Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 13 current format highlighting any areas of concern and whether specialist intervention is required. Improvement is in accordance with a verbal undertaking given by the manager during the last inspection. Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has clear policies and procedures in place which ensures residents are protected from abuse .The complaints procedure was satisfactory with evidence that residents are confident to use and feel their views/concerns will be acted upon. EVIDENCE: The home’s a policy and procedure which operates in tandem with the Hampshire County Council policy and procedure designed to protect vulnerable residents from abuse was available .Records to confirm all staff had received training in adult protection. Staff spoken with confirmed they were fully aware of the procedure to follow should they witness or suspect the abuse of any resident. The complaints procedure which was also included in the service users guide gave information on how to contact The Commission for Social Care Inspection (C.S.C.I) was seen as was a record of complaints that indicated no complaints had been received since the last inspection. Residents spoken to stated they felt comfortable in raising any concerns they had with the home’s management and confident any matters raised would be dealt with fairly and promptly but made it clear to the inspector “They never had concerns”. Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 15 Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 A safe, well maintained, clean and suitably furnished home and accessible garden is provided for service users which meets their needs. EVIDENCE: A tour of the building indicated that it was fit for its stated purpose, accessible, safe, well maintained and meeting residents individual and collective needs. Furniture was comfortable and homely and in keeping with the décor. Residents commented how satisfied they were with the accommodation. Since the last inspection, four bedrooms and the entrance hall has been re decorated ,four bedrooms have been re carpeted and curtains provided for the entrance hall as part of the on going maintenance programme. Following specialist assessments, a number of communal and personal aids have been provided. These include handrails, ramps, bath hoists, raised toilets, stair lifts and special beds . The home was clean, hygienic and free from adverse odours. An infection control policy and procedure was in place. Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 17 Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Residents needs are met by sufficient numbers of trained care staff who are recruited and selected using a procedure designed to protect all service users EVIDENCE: At the time of the inspection 5 carers, the manager a cleaner, a cook and a laundry assistant were on duty. The staffing level was adequate to meet the needs of the residents, an opinion shared by the residents who were full of praise for their carers. Care staff confirmed the level of staffing allowed them to deal with residents in an unhurried manner, putting the residents needs and wishes first. Records seen confirmed a very low turnover of staff who are recruited in accordance with the home’s selection and recruitment procedure which includes the completion of an application form, an interview and satisfactory Criminal Bureau Records(C.R.B.), Protection of Vulnerable Adults ( POVA) and reference checks. On commencement of employment all staff are subject to induction training (records seen) ,a period of probation and extra supervision before a final permanent position is offered. CRB checks for all existing staff have been carried out. Following induction and a probationary period all staff are expected to participate in an NVQ training programme. Currently 50 of staff have been trained to NVQ level 2, (35 of this figure to NVQ level 3) with a further 15 expected to finish NVQ level 3 shortly. A further 25 of care staff are involved in NVQ level 2. When all training is complete 50 of staff will be trained to level 3 and 25 to level 2. In addition to the above training all staff are Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 19 involved inl training covering the administration of medication, food hygiene, moving and handling, first aid and the protection of vulnerable adults and any other subjects as determined and agreed during regular one to one supervision(records viewed). Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32.33,35 and 38. A good quality assurance monitoring system and safe working practices ensure that the health, safety and welfare of residents and staff are promoted and the home is run in the best interests of the residents. EVIDENCE: Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 21 The home’s registered manager who has been in post for the past twenty two years, is qualified to NVQ level 4 and is also an appointed NVQ assessor. In compliance with regulation 26 The Registered Person visits the home on a regular basis, however at the time of the inspection monthly reports following visits had not been received by C.S.C.I. .The registered person acknowledged this oversight and gave a verbal undertaking that all missing reports would be sent to C.S.C.I. within seven days and in future sent monthly. These reports have now been received. Receipt of future reports will be closely monitored. Regular satisfaction surveys that seek the views of residents are carried out and records maintained including any action plans arising out of an analysis of resident’s replies. The surveys covered a wide range of topics including, choice, activities, food, staffing etc. A health and safety policy and procedure, Control of substances hazardous to health (COSHH) assessments, equipment servicing and accident records were available as were records to confirm all staff have receive training in the techniques of moving and handling first aid health and safety and the procedures to follow in the event of fire (including evacuation). All of the hot water supplies to baths were fitted with thermostatic controls set at 43 degrees centigrade and all radiators and hot pipes were covered. Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 23 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. 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. Refer to Standard Good Practice Recommendations Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Otterbourne Grange DS0000012155.V265042.R01.S.doc Version 5.0 Page 25 - 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!