Inspection on 17/01/06 for St Cross Grange

This inspection was carried out on 17th January 2006.

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

Other inspections for this house

St Cross Grange 01/02/07

St Cross Grange 21/07/05

St Cross Grange 08/11/04

St Cross Grange 15/06/04

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 St Cross Grange 140 St Cross Road Winchester Hampshire SO23 9RJ Lead Inspector Marilyn Lewis Unannounced Inspection 17th January 2006 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 St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 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. St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Cross Grange Address 140 St Cross Road Winchester Hampshire SO23 9RJ 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) 01962 854865 ght@stercrossgrange.fsnet.co.uk Greensleeves Homes Trust Ms Philippa Wrightson Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2005 Brief Description of the Service: St Cross Grange is one of seventeen care homes for older people, owned and operated by Greensleeves Homes Trust, a not for profit organisation. The home provides care for up to twenty-nine male and female residents over the age of sixty-five years of age. St Cross Grange is a large Victorian house, situated on outskirts of Winchester. Access to the M3 is a few minutes away and there is a local bus service nearby. There are local shops within a short distance and Winchester city centre is just over a mile away. The home comprises three floors, with accommodation provided on the ground and first floor and the top floor being used for management offices and additional storage space. Residents have access to a communal lounge, library, dining room and conservatory. The large garden is mainly laid to lawn, with car parking facilities to the front and side of the property. St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 17th January 2006. During the visit the inspector met with the six residents, the registered manager, deputy manager and three carer staff. Care plans were sampled for two residents and records seen for staff recruitment, staff training and medication. This was the second unannounced inspection for the year 2005/2006. Information on the standards assessed during the first inspection can be found in the inspection report dated the 21st July 2005. What the service does well: On the day of the inspection the home looked clean and welcoming. Residents spoken with felt they were treated with respect and were satisfied with the care provided. Good care plans are in place providing staff with the information they require to fully support the residents. Residents have their health needs met and are protected by the home’s clear procedures for dealing with medicines. The home provides residents with a choice of well-balanced meals. Residents are protected by staff awareness of abuse issues and the procedures to be followed should abuse be suspected. Resident’s needs are met by the number and skill mix of staff employed at the home. Staff receive regular supervision and the training required to do their jobs. The safe working practices operated in the home protects Resident’s health, safety and welfare. St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 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 St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 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): 6 People are not admitted for intermediate care. EVIDENCE: St Cross Grange does not provide intermediate care and therefore this standard is not applicable to the home. St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 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, 8, 9 and 10 Care plans provide good information on the assessed care needs of the residents, whose health care needs are fully met, who are treated with respect and are protected by the home’s clear procedures for dealing with medicines. EVIDENCE: Individual care plans are in place for each resident. Care plans were sampled for two residents who had recently been admitted to the home. The care plans provided good information on the assessed care needs of the residents and the actions required by staff to meet those needs. The plans included a personal profile of the resident that gave information on their past employment, interests and hobbies and family members. Details such as ‘the resident likes to rest after lunch’ were noted. Risk assessments for mobility and nutrition were contained in the care plans. The care plans seen showed regular review and involvement of the residents, who had signed the documents. Care plans seen provided evidence that the resident’s health care needs are fully met. The documents contained plans for personal hygiene, including the care for pressure areas and continence. Advice had been sought from GPs and district nurses and one of the records seen indicated that arrangements were St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 Page 10 in place for visits to a consultant at the local hospital. Visits by the chiropodist were recorded in one of the care plans and the resident has also attended an appointment at a local dentist’s practice. The home has clear procedures in place for dealing with medicines. Medication records seen had been completed appropriately. Records for medicines held in the controlled medication cupboard matched the stock held. Some residents wished to keep control of their own medicines and risk assessments had been completed to ensure they were safe to do so. During the inspection staff were seen to talk to residents in a friendly, respectful manner. Four residents spoken with said that staff were very caring and always treated them with respect. St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 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): 15 Residents are offered a choice of well-balanced meals. EVIDENCE: Since the last inspection a new catering firm have been employed to provide meals for the residents. Residents have been given the opportunity to feedback on the quality of food provided and their comments, mainly on the presentation of the meals, had been acted upon. Residents spoken with during the inspection all said that the food provided was good and that they had a choice at all meals. Lunch on the day was a choice of cottage pie or tuna pasta bake with fresh carrots and beans and lyonnaise potatoes, followed by treacle sponge and custard or fresh fruit salad. A cold meat salad had been provided for a resident who had requested it. The other standards in this section were assessed and met at the last inspection and information can be found in the inspection report dated the 21st July 2005. St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 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 Residents are protected by staff awareness of abuse issues and their willingness to act on any concerns. EVIDENCE: The home has policies and procedures in place for staff to follow should abuse be suspected, including Hampshire County Council’s the Protection of Vulnerable Adults and the organisation’s own documents. Two staff members spoken with knew about the procedures and indicated that they would not hesitate to report any concerns. Staff receive training on abuse issues during induction and arrangements are in place for all staff to receive further training in abuse awareness. St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 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): EVIDENCE: These standards were assessed and met at the last inspection and information can be found in the inspection report dated 21st July 2005. At the time of this inspection some areas of the home were being redecorated. Building work is taking place in one area of the grounds of the home where apartments are being built. The home is not involved with this accommodation. At present the builders are using the drive providing access to the home but this is only for a short time while a new driveway is being built and then access to the home will be separate. The registered manager said that the builders were liaising closely with the home to ensure disruption to the residents was kept to a minimum. A residents meeting has also been held to discuss the building work and keep residents up to date with the progress being made. St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 Page 14 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 and 30 Resident’s needs are met by the number and skill mix of staff employed, who receive the training required to do their jobs. However the safety of residents is put at risk by the home’s poor recruitment procedures. EVIDENCE: The home employs the registered manager, the deputy manager, five senior carers and nine carers. Separate staff are employed for administration, catering, laundry, domestic and maintenance duties. Staff and residents spoken with during the inspection said that sufficient staff were on duty for each shift. All of the senior carers hold NVQ level 2 or 3 and three carers also hold the qualifications. The deputy manager who is responsible for staff training said that arrangements were in place for more care staff members to commence the training for the qualifications. The home has introduced a new induction programme for all staff members including the carers already in post. The induction covers all aspects of care provision including health and safety, first aid, key working, risk assessments, personal care and dietary needs. All staff also receive training in moving and handling, fire prevention and infection control. Ten staff members had received training in food hygiene and the deputy manager said that she was arranging for a trainer to visit the home to provide training for the remaining staff. Some staff had also received St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 Page 15 training in challenging behaviour, dementia awareness, falls prevention, wound management, bereavement and care of hearing aids. Arrangements were being made for training in continence care. Staff spoken with said that they were encouraged to attend training sessions and to obtain qualifications. Staff records were seen for three staff members. The records contained photographs of the staff member and documents providing proof of identity such as passports. However one of the records contained only one of the two written references required and indicated that the staff member had commenced work at the home before Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks had been completed. Records for another of the staff members contained CRB and POVA checks from another company. These checks are not portable and this issue was discussed with the registered manager during the last inspection. There was no record of an application being made for the checks by the home. Staff members who do not have a CRB and POVA check completed must not work unsupervised until the checks have been received. No member of staff is to commence work in the home until at least a POVAFirst check has been completed. Requirements regarding the poor recruitment procedures at the home have been issued in the last two inspection reports and this is a cause for serious concern. St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 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): 36 and 38 Staff who receive supervision and the safe working practices in operation in the home protects residents. However the home’s poor recruitment procedures could put their safety at risk. EVIDENCE: The registered manager and the deputy manager provide regular supervision for the senior carers who in turn supervise the carers. The supervision meeting are held at times suitable to both parties and records are kept of the discussions, which include performance issues and training requirements. Staff who supervise have all received training in providing supervision for staff members. During the inspection hazardous substances such as cleaning fluids were seen to be stored securely. The kitchen looked clean and in good order. At the time of the last two inspections the temperatures of the fridges and freezers were St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 Page 17 not being monitored and recorded to ensure the food items were kept at the correct temperature. On this occasion records seen indicated that the temperatures were being monitored and recorded on a daily basis. The temperature of the hot water from bath taps was checked and found to be at the appropriate level. As previously stated in Standard 30, staff receive training in health and safety, moving and handling, fire safety, food hygiene and infection control. During the inspection staff were observed using safe working practices when providing care for the residents and health and safety notices were displayed around the home. St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 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 x x x N/A 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 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 x x x x x x x x STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 3 x 3 St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 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 OP29 Regulation 19(1)(b) Requirement The registered person must ensure that all information required in Schedule 2 of the Care Homes Regulations is obtained including two written references and CRB and POVA checks NO one is to commence work at the home until at least a POVAFirst has been obtained. Timescale for action 18/01/06 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 St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 Page 20 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 St Cross Grange DS0000011598.V275351.R01.S.doc Version 5.1 Page 21 - 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. 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