Inspection on 21/06/07 for Wellcross Grange

This inspection was carried out on 21st June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 17/01/06

Wellcross Grange 15/06/05

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 Mrs A Peace Unannounced Inspection 21st June 2007 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 Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 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. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellcross Grange Address Lyons Corner, Five Oaks Road Slinfold Horsham West Sussex RH13 0SY 01403 790388 01403 790140 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) Balcombe Care Homes Ltd Post vacant Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A total of 42 Service Users in the category older age not falling within any other category (OP) may be accommodated. A total of 38 Service Users in the category old age not falling within any other category (OP) may be in receipt of nursing care. 17th January 2006 Date of last inspection 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 a maximum thirty- eight residents who require nursing care may be accommodated at any one time. The property is a detached house, originally built in the 1920’s, 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 single and double rooms, many having en-suite facilities. Communal areas comprising of a reception area, a dining room, three lounges and a conservatory, are located on the ground floor. A lift provides residents with access to each floor. Balcombe Care Homes Ltd privately owns this service. The Responsible Person operating on behalf of the company is Mr David Williams; the manager is Mrs Judith Aldridge and is responsible for the day to day running of the care home. The current fees range from £606.00 - £975.00 per week. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Ann Peace carried out this unannounced inspection on the 21st June 2007. This inspection is the first inspection in 2006-2007. It is called a key inspection and will determine the frequency of inspections hereafter. Prior to the visit to the home the inspector reviewed the last inspection report and information gathered about the home. The Annual Quality Assurance Assessment was returned to The Commission for Social Care Inspection (CSCI) and this was used to address areas of improvement which the manager and provider had carried out and also identified areas for further improvement. During the visit a tour of the home took place with all communal areas and private accommodation visited. A case tracking exercise for five residents living at the home was undertaken to look at how the assessed needs of this group of residents with diverse needs are being met. Residents living at the home, staff working at the home and visitors to the home were spoken with to gain their views of the service. Staff were observed assisting and interacting with residents. The atmosphere at Wellcross Grange is relaxed and staff were observed to speak to residents in a friendly and respectful way. During this visit the records of two new staff were examined and staff were spoken with informally to find out what it is like to work at the home and to discuss aspects of residents care plans and assessed needs. The conclusion was that an excellent standard of care is delivered at the home from a dedicated, caring and well trained staff team. Some comments from people were: ”There is the peace of mind of having my mother cared for by such nice people”. “I could not be better cared for and the staff are attentive and kind”. “Nothing is too much trouble for the staff and that Matron always makes sure they we are all alright”. One visitor said they visit the home frequently at different times and the resident they visit “was always happy, content and well cared for”. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Following consultation with the residents about how to improve the service a new trolley to keep food hot was purchased and arrangements made to increase musical entertainment sessions. Also the routine for serving refreshments was changed. A dignity team has also been established to ensure the privacy and dignity of residents is high on the agenda in the home. Covered seating has been made available in the garden and work to establish a raised garden for wheelchair users is being carried out. A new care-planning format has been implemented and an advanced care plan designed. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 7 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 summary of this inspection report can be made available in other formats on request. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 8 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 Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective users of this service have the opportunity to make a fully informed choice about whether or not the home is suitable and able to meet their individual needs. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move into the home. Intermediate care is not offered at Wellcross Grange. EVIDENCE: Wellcross Grange has a statement of purpose/service user guide which is given to people living at the home and offered to people who are considering moving into the home. A copy was on display in the hallway of the home along with a copy of the last inspection report for the home and the findings of the residents and stakeholders quality standards annual review. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 10 Mrs Aldridge the Manager said that the Statement of purpose would be made available in a different format if necessary. The Statement of Purpose says that the home is driven by the needs, abilities and aspirations of the residents and not by management or staff; this was confirmed throughout the visit by observation and by speaking to residents, visitors and staff. Prospective residents are able to spend time in the home and the first 4 weeks is classed as a trial period. Six residents and four visitors said they had been given information about the home to enable them to make an informed choice about whether the home would be right for them. Staff spoken to knew what aims the home was trying to achieve for the residents. Case tracking confirmed good practice. Care plans had assessments of needs and the Annual Quality Assurance Assessment (AQAA) returned to CSCI stated that the Manager or Deputy Manager fully assess prospective residents needs prior to admission to ensure the home will be able to look after them. Assessments records seen confirmed this. Copies of the resident’s care management summary from Social Services are obtained and taken into account when planning care. A review of care is held in the fourth week following the resident’s admission and this is recorded in the residents file in the interim plan of care. Residents are consulted on their wishes and aspirations and these are incorporated as far as possible into their individual plan of care. Records of these were seen in resident’s files and residents spoken to did confirm that staff do try very hard to meet wishes and in the majority of cases do. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health and personal care that residents receive is based on their individual needs and the principles of respect, dignity and privacy are put into practice. Well-trained and skilled staff are committed in supporting residents and providing an excellent standard of care. EVIDENCE: All residents living at the home have an up to date day care plan and night care plan which has been developed from an assessment of need. The care plans of five residents were seen during the visit and a case tracking activity undertaken to see if resident’s plans reflected what they expected and whether they had any specialist equipment that was needed. The care plans detailed all aspects of health, personal and social care and the actions staff needed to take to meet these needs. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 12 A key worker system is operated in the home and staff were asked about their knowledge of residents who they are responsible for, all staff spoken to were knowledgeable about the residents their care needs and their previous lifestyle/family. Care plans are reviewed monthly and daily records are maintained to monitor any changes to the health and welfare of residents. Staff have handovers between each shift to ensure all staff are made aware of the ongoing condition of residents and any changes. This was evidenced by looking at the care plans and daily records, by speaking with staff about the residents and by asking residents whether staff do look after them how they wish. All residents spoken to were very complimentary about the way the home is managed and the way the staff support and care for them, they said that they are cared for to a very high standard by caring and friendly staff. Visitors also said that staff always make time to support them. Individual risk assessments are in place, for example: risk of falls, pressure area damage and malnutrition. Risk assessments are also completed if residents use any mobility aids such as wheelchairs. A monthly functional needs assessment is completed for all residents and monthly observations are recorded to enable residents health to be monitored. Records showed that residents have access to other health professionals as required and that outcomes from these visits are recorded. A physiotherapist visits the home on a weekly basis. Training records indicated that staff have the appropriate training to enable them to care for the residents. One resident said, “she could not be better cared for and the staff were attentive and kind”. Another said “nothing was too much trouble for the staff and that Matron always made sure they were all alright”. One visitor said they visit the home frequently and at different times and the resident they visit “was always happy and content and well cared for”. Two visitors said they had been invited to hold a family party in the home which made them very happy as their relative who lives at the home could play a major part at the party. The home is working towards The Gold Standard Framework. The aim is to have in place an advanced care plan as part of the admission procedure. For a number of residents advance care plans are already compiled where their wishes and aspirations are recorded so that in the event of a deterioration in their health where they would no longer be able make choices staff would know what they would like to happen. The staff communication book showed that little things that matter are done for residents such as heating wheat bags at a certain time or giving one Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 13 resident a thermos because they like to be independent when the want a hot drink. Following the results of the last quality assurance survey undertaken at the home and taking residents comments into account the home introduced a dignity team comprising of a nurse a senior carer and a carer. This team’s remit is to monitor staff working practices, take corrective action if necessary and undertake an annual review of dignity standards. We were told that this has raised awareness with staff when they are working and residents did say that staff do always respect their privacy and dignity. The medication administration procedures were discussed and policies and procedures are in place to ensure safe medication administration. A random selection of medication was checked and found to be in order. Medication administration charts (MAR) are completed as they should, which indicated that residents are receiving their medication as prescribed. Photographs of residents are with their MAR charts as an extra safeguard towards safe administration. Medication training is planned in the near future. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An activity programme is available and residents are encouraged to maintain contact with family and friends. Links with the local community are maintained. Residents are offered a varied diet of good home cooked food. EVIDENCE: Residents living at the home confirmed that routines were flexible and that they are encouraged to live the life they want to. Some residents said they prefer to stay in their rooms others were using the various communal areas. When residents are admitted the staff do try to compile a social history to ensure that the staff get to know the residents background so that any social needs can be identified. On the day of the visit some residents had newspapers which they were reading, others had books or were watching television in their rooms. A number were in one of the lounges listening to classical music. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 15 One lady was arranging the floral table decorations for the dining room with the help of a member of staff. In the AQAA returned to CSCI the manager identified that due to the loss of the activity co-ordinator, activities had not been as varied as they would have liked and that his was mentioned by residents in the last quality assurance survey. We were told that an advertisement was presently in the press and there were plans to develop the social activities further when someone was appointed. There are activities at present on a daily basis carried out by the staff these included music, music and muse society, exercise, games, gardening, films, games and 1-1 activities. Two residents said they had enjoyed the gardening. There are plans to make some raised flower beds in the near future so that residents including those in wheelchairs will be able to potter about. Entertainers do visit the home and in June there was a magician booked and also an owl display. Local schools come into the home to entertain and photographs were on the wall of the occasion. From the photographic displays seen the home do have lots of occasions when they have parties and celebrations. One display for the Queens birthday showed that residents were asked to choose a favourite picture of the Queen and a collage was made of the pictures. The home also had afternoon tea with cake and candles to celebrate. A congratulations letter from the residents was sent up to Buckingham Palace and a reply was received. Mrs Aldridge was reminded that if staff are allocated for activities then these hours should be over and above the hours for caring. Another area where the home hopes to improve is the accessibility to transport to enable residents to go on more outings. The home also has a target to re establish a full social and recreational programme by August 2007 and to improve community links by January 2008. Residents can either eat in the dining room or in their rooms. At present building work is being undertaken at the home and includes a plan to extend the dining room to make life easier for wheelchair users. Weekly menus are displayed on notice boards around the home. Following the last quality assurance survey where residents commented that some lunches were not hot enough a new heated food trolley was purchased to overcome the problem. Residents spoken to said the food served was good and there was always a choice. Residents are asked what they would like to order the day before but did say that if they changed their minds they were able to have the meal of their choice. The main meals are served at lunchtime and on the day of the visit there was roast pork with roast potatoes and mixed fresh vegetables, or cauliflower, egg Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 16 and spinach gratin followed by orange sponge and lemon sauce or crushed pineapple mousse. The meals were sampled and were very tasty and well presented. Residents spoken to said they enjoyed their meals; staff assisted residents who needed help in a caring sensitive and unhurried manner. Drinks and snacks are available if residents wish, also alcoholic drinks are available. Two visitors told us that when there was a recent special occasion in the family involving a resident at the home they were offered a room in the home to hold a family party. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents who use this service or their representatives are able to express concerns, and have an access to a robust, effective complaint procedure, are protected from abuse and have their rights protected. EVIDENCE: The home has a complaint procedure which is outlined in the statement of purpose and displayed prominently in the home. Complaints are recorded and investigated with feedback to complainant within 28 days. All residents and visitors spoken to said they knew who to complain to and that they would not hesitate to do so if they though it appropriate. They did say that Mrs Aldridge the manager when on duty was always available if they did want to speak to her. Staff said that they did realise the importance of taking the views of the residents seriously. CSCI has not received any complaints or concerns regarding Wellcross Grange. Staff induction and training records indicated that all staff have received training in safeguarding vulnerable adults and staff when spoken to did know what to do if they suspected abuse. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 18 When asked, residents said they felt safe at the home and said staff do listen to them but that they would feel able to speak to the staff or manager if they were not happy with anything to do with their care. CSCI were told that the plan for the future is to develop staff understanding of how complaints can be used to improve service delivery. There is also an adult protection workshop planned for all staff in December 2007. All residents have access to the postal voting system if they wish. Information on advocacy services is displayed and are accessed if needed. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, safe, well maintained and offers residents a comfortable, pleasant environment to live in. EVIDENCE: Wellcross Grange is a converted Manor House and has been a care home since 1985. The home is comfortable, well furnished, well maintained and has a homely atmosphere and the location and layout is suitable for its stated purpose. The home is situated in a country setting and the grounds well maintained. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 20 To the front of the home there is a stream and pond with ducks and there are various covered seating areas for residents to enjoy. This area and access to it has been improved following comments from the last resident’s quality survey. At present some building work is being undertaken to extend the dining room to enable better access for wheelchair users and to build three more en-suite bedrooms. A wheelchair store is also planned. Residents whose bedrooms overlook the building work said that there had been very little disruption and that they were pleasantly surprised at the lack of noise. Notices had been displayed around the home explaining about the building works. All areas of the home are very clean and hygienic. Resident’s bedrooms showed that they have been able to personalise their rooms as they wished and all communal areas are well decorated and furnished in a homely fashion. There is a conservatory which some residents said they enjoy sitting in. The fire procedures, risk assessments and safety checks are recorded and detailed. Infection control measures are in place to minimize the risk of infection and cross infection, alcohol hand gel is provided throughout the home and there is a plentiful supply of gloves and aprons available for staff. Aids and equipment are supplied to meet staff and resident’s needs and all residents who require nursing have adjustable nursing beds. Toilets and bathing facilities are adequate for the residents presently accommodated and sluices are provided. A lift is available for residents whose rooms are on the first floor and records showed that this is serviced regularly. A call bell system is available throughout the home and screening provided in share rooms. Emergency lighting is provided throughout the home and regular safety checks on the system are made. Mrs Aldridge told us some doors still had not got automatic closures that would ensure doors closed in the event of a fire but that some have been ordered. Records showed that water temperatures are tested to ensure the water is not too hot to cause harm. Mrs Aldridge was not sure is a test for Legionella has been undertaken but said she would find out and take action if necessary. The laundry and food store is situated a short distance away from the main house there are plans fro a covered walkway in the present building work. The floors to both areas are not impermeable are in poor repair and need attention, also the shelves that the food stores are on need attention as the covering is ripped. We were told that work to the floors and other areas would be carried out when the building work starts in that area in the near future. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 21 Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support and care for residents who live in the home. EVIDENCE: The staff duty rota was available in the home and the staff on duty were observed to be well organised and able to respond to the needs of the residents. Qualified nurses are on duty 24 hours a day and in addition there are care staff, cleaning staff, maintenance staff, kitchen staff and an administrator. There is also a manager on call system in operation in case of emergencies. Residents living at the home and the visitors on the day of the visit spoke highly of the staff and the way the home is run. There is a staff training and development plan in operation, staff records indicated that staff have mandatory training in fire safety, first aid, health and safety and safeguarding adults. Although few care staff have training in safe food handling although they do sometimes serve food and feed residents who need help. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 23 Other staff training is provided related to roles and responsibilities. National Vocational Training (NVQ) is encouraged but at present the home is not meeting the standard for the required 50 of the staff to be trained to NVQ level 2. The home are trying to meet the standard and some staff are undertaking their NVQ’s. However the home has a low turnover of staff and many of the staff have been working at the home for a long time and some do not want to undertake the qualification, although they all undertake regular in house training. In this case we concluded that this is not affecting the outcomes for the resident’s as the standard of care from the staff is excellent but that NVQ training should still be encouraged. The training planned indicated that staff training is focused on improving outcomes for residents and qualified nurses could demonstrate that they take responsibility to keep themselves updated related to their registration requirements. The records of two new staff employed since the last inspection were examined and contained all of the information required by legislation and to ensure the staff are safe to work with vulnerable people. Interview notes are held and new staff undertake an induction process although one could not be found on the day of the visit. The member of staff was spoken to and did confirm he had undertaken a thorough induction. A staff supervision and appraisal system is in operation at the home and staff spoken to said that they felt well supported and had the appropriate training to be able to care for residents and keep them safe. Those spoken to could demonstrate that they had a good understanding of the particular needs of the residents and the care that was needed. Staff meetings are held and involve staff in consultation and the development of the service and training. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,25,36,37,38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents benefit from a well run home which has a competent manager. The management and administration of the home is based on openness and respect. An effective quality assurance system is in operation and residents are protected by the health and safety practices in the home. EVIDENCE: The manager Mrs Aldridge is a first level nurse and an experienced manager who has attained The Registered Managers Award. Mrs Aldridge has been manager of the home since early 2007 and was the deputy manager Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 25 previously. Mrs Aldridge has now applied to the Commission to become the Registered Manager for Wellcross Grange. Residents living at the home, visitors and staff had positive things to say about Mrs Aldridge when they were spoken to. Mrs Aldridge was able to demonstrate that she exhibits a clear sense of direction and strong leadership in the home based on improving and maintaining the high standards of care for residents. The home has a robust quality assurance system which showed that action is taken when residents or other stakeholders identify shortcomings and that the main purpose is to improve outcomes for residents. The results of the last survey were seen and note taken of action taken. Residents meetings are held and minutes available. Regulation 26 visits are made by a representative of the company on a monthly basis to monitor how the home is running, reports are kept at the home and it could be seen that when issues are identified that need attention these is carried out to the benefit of residents and staff. Safeguarding the health and safety of people living at the home and people working at the home is a high priority, with systems and records being in place to show the constant monitoring of its own practice. Following the monitoring of the accident records it was identified that one resident would benefit from a sensor pad which alerts staff if they get up, by using this, the risk of this resident falling has been minimised. There is an established system for reviewing health and safety standards and risk assessments and maintenance and safety check records seen are up to date and well maintained. The AQAA reported that records of financial transactions are kept up to date and secure facilities are provided for the safekeeping of money and valuables on behalf of the residents. One relative said ”there is the peace of mind of having my mother cared for by such nice people”. Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 26 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 X 4 4 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 4 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 3 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 3 3 3 Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 27 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. Refer to Standard OP12 Good Practice Recommendations It is recommended that an activities co-ordinator be recruited as soon as possible. It is recommended that safe food handling training be part of the staff training and development plan. OP30 Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Wellcross Grange DS0000040966.V338793.R01.S.doc Version 5.2 Page 29 - 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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