Inspection on 23/01/06 for The Grange Chertsey (2002) Ltd

This inspection was carried out on 23rd 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 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

The Grange Chertsey (2002) Ltd 15/05/07

The Grange Chertsey (2002) Ltd 02/09/05

The Grange Chertsey (2002) Ltd 09/12/04

The Grange Chertsey (2002) Ltd 17/06/04

The Grange Chertsey (2002) Ltd 23/02/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Grange Chertsey (2002) Ltd The Grange Ruxbury Road St Anne`s Hill Chertsey Surrey KT16 9EP Lead Inspector Damian Griffiths Announced Inspection 23rd 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 The Grange Chertsey (2002) Ltd DS0000013655.V272182.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. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Grange Chertsey (2002) Ltd Address The Grange Ruxbury Road St Anne`s Hill Chertsey Surrey KT16 9EP 01932 562361 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) The Grange Chertsey (2002) Ltd To be confirmed Care Home 46 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (46), of places Sensory Impairment over 65 years of age (8) The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Within the categories `OP` (OLDER PEOPLE), sixteen may be within the category DE(E) and eight may be SI(E) 2nd September 2005. Date of last inspection Brief Description of the Service: The Grange is a large detached property set in spacious private gardens. A number of staff live on the premises. The staff team consists of: Registered Manager, Deputy Manager, Senior carers, Care assistants, Cook, Catering staff and Cleaners, with the regular involvement and support of the proprietor. The service provides twenty-four hour care for up to forty-six older people. All bedrooms are single size and all have en-suite facilities that include a toilet, basin and bath. There are spacious communal areas that include two lounges, two dining rooms and a bright and airy conservatory looking out onto the main gardens. The service provides a range of activities and events for residents to attend both in-house and within the local community. Please note: Due to the template being produced prior to the new registration of Manager Mrs Lizzie Mc William it has not been possible to include her name in the ‘Name of Registered Manager’ section of this report but will be included in future reports as appropriate. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of two to be undertaken in the Commission for Social Care Inspection Year April 2005 to March 2006. It was an announced inspection and took place over a period of 7 hours. Lead Inspector Damian Griffiths was assisted throughout the inspection by Mrs Lizzie Mc William, Registered Manager and by the owner Sean Costelloe representing the establishment. The inspector consulted six residents and three support workers who were able to contribute to the inspection report. Twelve comment cards were distributed before the inspection and returned: Residents, family, social care and health practitioners completed these. A tour of the premises was conducted: staff rota’s, six care plans and three staff files were sampled, and a pre-inspection report was submitted. The Inspector was invited to stay for lunch and was able to sample the food and inspect the menus first hand. The inspector would like to extend his thanks to the residents, staff and management at The Grange and also health and social care practitioners for their assistance and hospitality. What the service does well: The high standard of accommodation at The Grange provides a comfortable, safe and homely environment for the residents. Information about the home contained in the service users guide and statement of purpose was clearly written and addressed issues helpful to new and existing and residents. Residents care plans were easy to follow, comprehensive and containing accurate and up-to-date health care information. Staff were seen to be responsive and sensitive to the needs of the residents throughout the Inspection. Meals were well prepared tasty, nutritious and varied. Fresh fruit and vegetables were available daily. Residents had a choice of meals and specialised diets were catered for. The Inspector requested a vegetarian meal, not featured on the day’s menu. It was prepared and presented without fuss. Residents stated: …the food had definitely improved; the food was lovely, …a good selection and never any fuss. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 6 Staff rotas were inspected to see what staff were on duty and to compare their skills with the residents needs. Staff moral was good and the training and experience of staff compared and reflected the needs of the residents well. The home is to be congratulated for its well-rounded approach to care provided to the residents at The Grange. 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. The Grange Chertsey (2002) Ltd DS0000013655.V272182.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 The Grange Chertsey (2002) Ltd DS0000013655.V272182.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 and 4. The Statement of Purpose and Service User Guide were good, providing residents and prospective residents with details of the service that the home provides enabling an informed decision to be made. Contracts of the service provided were available and comprehensive however some were incomplete and in need of further action. EVIDENCE: Residents and prospective residents were provided with adequate information relating to the home. There have been two new residents since the last inspection and residents consulted were satisfied with the level of information available however were not aware of the training levels acquired by staff. Information of the skills attained by the staff would further enhance the information available. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 9 Six resident contracts were inspected: they contained information relating to the terms and conditions of the residency. There were a few aspects of the contracts that were in need of completion including: some that were not signed and one that required the resident’s local authority to be completed. Letters to the parties involved were immediately actioned and to the satisfaction of the Inspector. See the requirements and recommendation section of this report. The Grange Chertsey (2002) Ltd DS0000013655.V272182.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 and 8. The Health and social care needs of residents were well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: Six care plans were inspected and each had a clear and comprehensive assessment of need that was the basis of the information contained in the files. Attention to: personal care, rest and sleep, social daily activities were carefully documented with the addition of the residents health care needs including regular recording, and in some cases, daily monitoring of: blood sugar levels, blood pressure, weight and pressure sore management. The homes policy provides staff with clearly written and comprehensive guidelines to follow. Residents consulted said they were very pleased with the care the received and one resident stated that: ‘they always make sure I don’t miss a hospital appointment’. Other comments received from residents included praise for the home entertainment over the holiday period: ‘we enjoyed the Panto this year and the Christmas celebrations were good ’ The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 11 Comments received from health care practitioners confirmed that the home was able to demonstrate a clear understanding of the care needs of the residents and ‘showed compassion and understanding’ concerning a resident who was able to make a successful transition from hospital and to become ‘the life and soul’ of the home. The Grange Chertsey (2002) Ltd DS0000013655.V272182.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): 15. The dietary needs of residents were well catered for with a balanced and varied selection of food available that met resident’s taste and choice. EVIDENCE: Residents have dinner served in two dining areas to: one small and discrete area for residents requiring additional help and another in the main dining area. Residents were not segregated but were able to receive a degree of privacy. The choice of meals varied weekly and residents had access to printed menus. Two chefs are employed to work a morning and afternoon shift and were available for residents to consult. Special diets were catered for and attention was paid to the salt and sugar content of the meals. Attention to the needs of then residents has earned the home being awarded the ‘Young at Heart ‘ certificate awarded by Runnymede Council ‘for quality, variety and nutritional value’, as quoted by the local press. A resident’s relative commented on the ‘standard and variety of the food as ‘excellent’. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 13 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 adequate Complaints and Protection of Vulnerable Adults policy and procedures in place. And staff were able to demonstrate knowledge of the circumstances that would prompt action. EVIDENCE: Service users, relatives, social and health care practitioners commented on the quality of the homes practice and confirmed that there had been no cause for complaint. There were no complaints recorded or received at the time of the inspection and the home had policy and practice guidelines available. Residents consulted were confident in the management’s ability to respond to their concerns. Residents consulted felt safe and well cared for and letters of commendation had been received from residents and their families. Comments received from relatives stated that they were ‘happy with the care’ and Social care and Health practitioners were able to see residents in private and were notified of significant events affecting their client/patient. Residents had ticked the comment cards in the following sections: feeling safe, well cared for and enjoying living at The Grange. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 14 Staff consulted were aware of the importance of adhering to the protection of vulnerable adults policy and procedures but were less confident in their knowledge of the whistle blowing procedure. See the requirements and recommendation section of this report. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 15 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): 19,23 and 26. There was a clear development and refurbishment plan for the home that did not detract from the standard of care available at the home providing the residents with an attractive and homely place to live. EVIDENCE: A tour of the premises was conducted with the assistance of the owner Mr Costelloe. There had been significant improvements made since the last inspection including: the first floor corridors that had been tastefully decorated presenting a clean, light and pleasant area for the residents to enjoy. New and unobtrusive handrails, ground level night-lights added to the safety of the corridors and created a restful and ambient night-light. Vacant rooms were being redecorated and existing resident’s rooms contained all the necessary furnishings required. They were all clean, tidy and reflected the individual residents personal taste. One relative commented on his Mothers room saying that it had a ‘ homely feel’ and thought the ‘standard of decoration’ was good. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 16 The home has recently completed re-tiling the conservatory area that overlooked the garden that was well maintained and dominated by a magnificent Redwood tree in the centre. The owner is to be congratulated on showing forethought about seeking advice about the maintainence of trees within the borders of the home. Relatives of one of the residents visiting the home regularly commented on the owner’s dedication to improve the home and the care the staff take to provide a consistently clean environment …‘particularly noticeable is the lack of unpleasant smells’. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 17 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 and 29. The skill mix of the staff team was good and staff were receiving appropriate training to meet the needs of the service users to ensure their safety and welfare. The recruitment practice was sufficient to meet the required needs however there were some areas that required attention. EVIDENCE: Three staff files were examined and staff consulted. The staff rotas for the week were inspected and the skill mix and experience of care staff was judged by the training they had received. The files showed that they had all received a basic induction-training programme that included core skills such as: Safe handling of medication, Food hygiene, First aid, Manual handling, Adult protection and Fire safety skills. The manager was committed to continuous professional development and was developing improved staff training records. Staff consulted had good knowledge of individual residents care needs. Staff were available throughout the night and senior care staff were available on each shift. 50 of staff had attained level 2 of the National Vocational Training awards. One of three staff files inspected did not contain a full employment history and one did not have the required amount of references however the staff member had been employed over a number of years and had exhibited a good knowledge of residential care skills. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 18 One relative stated that: ‘the staff were always welcoming, well trained and committed’ and felt that ‘staffing numbers are above the minimum requirements’. Relatives, Social care and Health practitioners were always able to see a senior member of staff, acknowledged that care plans were followed and that they were satisfied with the overall care provided. See the requirements and recommendation section of this report. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 19 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): 31,33,35 and 38. The manager had a good understanding of the areas in which the home needs to improve and was well supported by senior staff providing clear leadership in all areas. Recent awards actively served to demonstrate that the home was run in the best interests of the residents. The health and safety of the service users was respected and catered for adequately. EVIDENCE: Since the last inspection the manager has been registered with the Commission on the basis of her experience and commitment to complete her Registered Managers Award. Staff consulted felt well supported and were happy working at the home. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 20 The homes recent award for ‘Young at Heart’ and the ‘Investors in People’ demonstrated recognition of the commitment to promote residents and staff active participation to ensure that quality of life issues at The Grange were maintained. Residents, relatives, social and health care practitioners and staff consulted felt included and participated with various aspects connected with the running of the home. Resident’s finances were not dealt with by the home but were left to the residents, relatives or representatives to manage. There were full guidelines made available to the ‘Residents Association’ offering information about extra costs being included in resident’s monthly charge account for their convenience. The home also had guidance for staff relating to gifts from appreciative residents that helped promote the protection of staff and residents and in line with the vulnerable adult guidelines. Health and safety policies and practices were observed and being actioned. COSHH, RIDDOR, Fire safety, smoking and risk assessments were actively promoted and an accompanied by a full training program. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 21 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 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No 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. 1. 2. 3. 4. Refer to Standard OP1 OP2 OP18 OP29 Good Practice Recommendations It was recommended that the Service Users Guide be updated to include the relevant staff qualifications that had been achieved. It was recommended that the manager review all resident contracts to ensure they have been completed and make copies available to residents and their representatives. It was recommended that the staff are made familiar with the whistle-blowing procedure. It was recommended that recruitment files be checked to ensure that they all include the required documents as listed in schedule 2 of the Care Homes Regulations. The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 The Grange Chertsey (2002) Ltd DS0000013655.V272182.R01.S.doc Version 5.0 Page 24 - 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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