Inspection on 15/06/05 for Wellcross Grange

This inspection was carried out on 15th June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wellcross Grange 21/06/07

Wellcross Grange 17/01/06

Wellcross Grange 12/01/05

Wellcross Grange 23/07/04

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 Wellcross Grange Lyons Corner, Five Oaks Road, Slinfold Horsham West Sussex RH13 0SY Lead Inspector David Bannier Unannounced 15 June 2005, 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Wellcross Grange Address Lyons Corner, Five Oaks Road, Slinfold, Horsham, West Sussex, RH13 0SY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01403 790388 01403 790140 Balcombe Care Homes Ltd Mrs Elizabeth Lawrence Care Home (CRH) 42 Category(ies) of Old age, not falling within any other category registration, with number (OP),(42) of places Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 A total of 42 Service Users in the category older age not falling within any other category (OP) may be accommodated. 2 A total of 38 Service Users in the category older age not falling within any other category (OP) may be in receipt of nursing care. Date of last inspection 12 January 2005 Brief Description of the Service: Wellcross Grange is a Care Home which is registered to provide nursing and personal care to a maximum of forty two residents users in the category old age, not falling within any other category. A condition of registration is that up to thirty eight residents who require nursing care may be accommodated at any one time. The property is a detached house, originally built in the 1920s which is set in its own extensive grounds and is located in the village of Slinfold, near Horsham. The property has been extensively improved and adapted to ensure it is suitable for its current use. The accommodation comprises thirty single bedrooms, twenty six of which have ensuite facilities and six double rooms, all having ensuite facilities which are located on the ground and first floors. Communal areas comprising of a reception area, a dining room, three lounges and a conservatory, are located on the ground floor. A vertical lift provides residents with access to each floor. The service is privately owned by Balcombe Care Homes Ltd. The Responsible Person operating on behalf of the company is Mr David Williams, whilst the Registered Manager is Mrs Elizabeth Lawrence and is responsible for the day to day running of the care home. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 10am. It took place over six and half hours. The inspector spoke separately to three residents, some of whom had been admitted since the last inspection and three residents who were taking part in a gentle exercise session. The inspector also spoke to the Deputy Manager, the registered nurses, the care staff and the catering staff who were on duty. The inspector also looked around some areas of the care home, including the communal areas and bedrooms that have been built since the last inspection. Some records were also examined. What the service does well: What has improved since the last inspection? Recruitment and induction procedures have improved so that staff who are employed to work at Wellcross Grange are safe to work with vulnerable residents. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) As the standards in this section were met during the last inspection, none of these standards were assessed. EVIDENCE: Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 Where possible residents are involved with the drawing up of their own care plans. Otherwise their family or close friends have become involved in this process. Care plans have been developed out of assessments. The information provided to staff was sufficiently detailed to ensure residents’ health care needs have been met. From the comments made by residents it would appear that the staff members respect the privacy and dignity of the people living at Wellcross Grange. EVIDENCE: The inspector read a selection of care plans. The records were informative and included appropriate information for staff to follow to ensure the way care is provided is in accordance with the wishes of each resident. At the change of each shift staff who is coming on duty meet together with the nurse in charge to discuss events, which have occurred during the previous shift to ensure residents receive care in a continuous and consistent manner. Following discussions with the nursing staff it was suggested that care plans are looked at carefully to ensure the information provided for staff to follow is clear so that staff are caring for each resident in an appropriate way which has been agreed with each resident concerned. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 10 Residents said that they felt well cared for. They told the inspector that: “staff are helpful”; “ staff are very kind and caring, I can’t fault them;” “I have explained to staff how I wish to be cared for, and it has worked.” Residents also said that sometimes they have to wait before they are attended to “the staff seems to be very busy; “they sometimes look cross and are very busy”. The staff on duty also told the inspector that, since the new wing has been built they find they have to care for more residents with the same number of staff. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 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 standard(s) 12,13,14, and 15 Residents at Wellcross Grange are able to make the day-to-day decisions about how they want to live their life. There is a range of activities for those who wish to participate. Residents are encouraged to maintain contact with all their old friends and family wherever possible. The food is of a good standard, and offers a choice of menu. People are able to eat together or in their own room should they prefer. Sufficient staff is available to assist those residents who need help and supervision with eating and drinking. EVIDENCE: At the time of the inspection a gentle exercise session was taking place in the lounge. Four residents were taking part. Afterwards one resident commented that the session was enjoyable and she enjoyed learning something new every week. Another resident told the inspector that there was an organist due to visit that afternoon and she was looking forward to the session, so long as it is not too noisy. Information about a range of activities was displayed on a notice board just outside the lounge. A record of each resident’s personal interests and hobbies has been kept to ensure, wherever possible, activities that are arranged are in Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 12 keeping with individual wishes and preferences. Everyone said they enjoyed the activities, which have been put on for them. There was also a display of photographs that had been taken of a party to celebrate a resident’s 100th birthday. All the residents who were spoken to said that they keep in touch with family and friends. They enjoy regular visits from sons and daughters, grand children and, sometimes, great grand children! One resident keeps in touch with family members who do not live nearby by telephone. The inspector watched whilst the main meal of the day was served. The meal consisted of a choice of beef cobbler or fisherman’s pie, mashed potatoes, spinach and peas followed by a choice of apple and mincemeat crumble or tinned fruit salad and custard. Small portions of each of the first course were sampled, and were very tasty. The meal, including those which needed to be liquidised, was attractively presented. Some residents, who did not wish to go to the dining room, were able to have their meal in the comfort of their own room. Those residents who required help with eating were attended to by staff that sat with the resident and provided appropriate assistance. One resident told the inspector that she had made a complaint that she found the food was cold. However, the matter was investigated and it has now put right to her satisfaction. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 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 standard(s) 16 A written complaint procedure has been made available for all residents to use. Complaints, which have been received, have been taken seriously and appropriation action has been taken to resolve the concerns raised. EVIDENCE: Records of complaints were seen, which showed that complaints received have been investigated and, where necessary appropriate action has been taken to put right anything which residents, or their relatives have been unhappy about. A written complaint procedure was on display outside the main office in an appropriate format. It clearly explains who should be spoken to and the timescales by which the provider expects to resolve any concerns raised. One resident told the inspector that she had raised a number of concerns that she had. She also confirmed that each of them had been looked into and put right to her satisfaction. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 On the day of the inspection Wellcross Grange was clean, appropriately furnished, decorated in a homely manner and well maintained. This made it very pleasant for residents who live in the home. The location of the home is suitable for the residents who live there. The care home was clean, pleasant and hygienic. EVIDENCE: During the course of the inspection the bedrooms in a wing, which had built since the last inspection, the lounges and dining room were visited. The environment was attractively presented and was homely, safe and comfortable for people who live there. Many residents had brought personal possessions into the home, including small items of furniture, ornaments and photographs. Residents have been able to use these items to make their own rooms comfortable and to reflect their own personality. One resident said that she has been able to equip her room with facilities to make herself hot and cold drinks and snacks if she wants to. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 15 Residents told the inspector that they were very satisfied with the private accommodation and that they were very comfortable. Outside work has been completed on the driveway at the front of the house. Mr Williams arrived whilst the inspector was visiting. He said that he had further plans to provide pathways all the way round the outside of the house also to provide a pathway to a sitting area, with covering, by the side of the large pond, located in the front of the house. This will enable residents to have total access and to be able to enjoy the extensive grounds. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Wellcross Grange is adequately staffed with employees who are skilled and experienced in caring for older people. Induction training is provided for all new staff. All staff is provided with opportunities to undergo training leading to National Vocational Qualification awards at Levels 2 and 3 in caring for elderly people. Other training to improve the knowledge and skills of the staff in the care of the elderly is also provided. All training is recorded on staff member’s files. The care home operates a thorough and robust recruitment procedure that ensures the safety and wellbeing of residents. EVIDENCE: Rotas were seen which showed that staffing levels, including trained nurses, catering and domestic staff were sufficient to ensure residents are well cared for. However, some residents said that they had to wait for some time before they were attended to. Residents also said this was because the staff were very busy. Mr Williams informed the inspector that he has been made aware of this. He is currently undertaking a review of staffing levels and in particular shift patterns to ensure there is sufficient staff available to provide care to the residents. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 17 Residents said that they felt well cared for. They told the inspector that: “staff are helpful”; “ staff are very kind and caring, I can’t fault them;” “I have explained to staff how I wish to be cared for, and it has worked.” It was clear from staff records that appropriate information and documents have been obtained with regard to all staff who had started work since the last inspection. This means that residents’ safety and wellbeing has been safeguarded. The inspector attended a meeting with the nurse in charge and the staff who were starting the afternoon shift. The staff clearly understood the needs of the residents who were being accommodated and they how they were expected to meet them. Records seen showed that each member of staff had been provided with appropriate training, including induction training. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 37 Mrs Lawrence, the registered manager, is providing clear leadership and management to her staff to ensure residents are well cared for. Records seen were being securely kept, up to date and well maintained to ensure residents’ rights and best interests have been safeguarded. EVIDENCE: Mrs Lawrence was not available at the time of this inspection. However, following discussions with the staff on duty it was clear that they knew what was expected of them. They explained to the inspector that they were expected to listen to residents and to treat them with respect and with dignity. From observation of care practices and discussions with residents it was obvious that this ethos was being put into practice. A selection of records was seen that were being appropriately kept. These included care plans, staff records, rotas, records of visitors to the care home, records of food provided, complaints and accidents. Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 19 Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x 3 x x x x 3 x Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Wellcross Grange H60-H11 S40966 Wellcross Grange V224633 150605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 2nd Floor, Ridgeworth House, Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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