Care Home: Capel Grange

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What the care home does well The manager runs the home in the best interests of the residents and has a quality assurance system that is based on the views of the residents and other stakeholders. A well-trained and stable workforce cares for residents needs and encourage them to maintain their independence as far as they are able. Residents are supported to maintain contact with their friends and relatives. Residents are treated with respect and their privacy is upheld. The home is comfortable and well maintained and is sited in lovely grounds, which are accessible to the residents. Relative comment cards included the statements, `From what I have seen the care this home gives to their residents is of a high standard every care is taken to help the residents to settle and enjoy the rest of their lives as best suited to them`, and `They provide a very friendly and professional service`. A staff comment card said, `The home gives very good care to the service users`, and a member of staff said, "Everyone is friendly and professional". What has improved since the last inspection? The requirements and recommendations made on the last report have all been actioned. Care planning has improved and now includes more involvement of the residents. There are more activities on offer to the residents and the recent appointment of a new activities co-ordinator will further enhance this. There is now a higher staff ratio to give better care to the residents. Additional staff training has taken place A variety of environmental improvements have been made and additional cleaning staff have been employed. What the care home could do better: Some improvements are needed to the recording of drugs received and disposed of. No requirements have been made on this report. CARE HOMES FOR OLDER PEOPLE Capel Grange Maidstone Road Five Oak Green Tonbridge Kent TN12 6QY Lead Inspector Chris Woolf Key Unannounced Inspection 5th February 2008 09:25 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 Capel Grange DS0000065623.V357939.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. Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Capel Grange Address Maidstone Road Five Oak Green Tonbridge Kent TN12 6QY 01892 834225 01892 834225 care@capelgrange.co.uk 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) Safequarter Ltd Mrs Sara Grist Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 38. Date of last inspection 18th September 2006 Brief Description of the Service: Capel Grange is a care home providing personal care and accommodation for older people. Currently the home can accommodate 33 service users but alterations to form a link extension to an adjoining cottage are almost complete and this is due to open in March 2008 at which time the numbers will increase to 38. There are two passenger lifts in the existing building giving access to the first floor. The house stands in its own grounds in three and a half acres of garden, with lawns and paved areas accessible to service users. The home is located on the outskirts of Five Oak Green, which has a small selection of shops, pubs and other amenities. Paddock Wood is a short distance away where there is a wider selection of amenities and a main line station. The current fees for the service at the time of the visit range from £316.11 to £496.00 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is care@capelgrange.co.uk Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. The information for this report is based on information received throughout the year; an Annual Quality Assurance Assessment (AQAA) completed by the home; Comment cards received from 9 service users, 5 relatives, and 2 members of staff; and a site visit to the home lasting 6 hours and 40 minutes. The site visit was unannounced. This means that neither the manager and staff or the residents knew that we (the Commission) were going to visit. During the visit we spoke with the majority of the residents, two at some length. We also spoke with two visitors, the staff on duty, and the manager and administrator. We had a tour of the building; observed the interactions between the staff and the residents; saw a meal being served; and witnessed the lunchtime administration of medication. We also inspected a variety of records including care plans, staff files, medication records, and menus. The people who live in this service prefer to be called residents and this is the term used to describe them throughout the report. What the service does well: The manager runs the home in the best interests of the residents and has a quality assurance system that is based on the views of the residents and other stakeholders. A well-trained and stable workforce cares for residents needs and encourage them to maintain their independence as far as they are able. Residents are supported to maintain contact with their friends and relatives. Residents are treated with respect and their privacy is upheld. The home is comfortable and well maintained and is sited in lovely grounds, which are accessible to the residents. Relative comment cards included the statements, ‘From what I have seen the care this home gives to their residents is of a high standard every care is taken Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 6 to help the residents to settle and enjoy the rest of their lives as best suited to them’, and ‘They provide a very friendly and professional service’. A staff comment card said, ‘The home gives very good care to the service users’, and a member of staff said, “Everyone is friendly and professional”. 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 summary of this inspection report can be made available in other formats on request. Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 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 Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 & 5. Standard 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have their needs assessed and the opportunity for a ‘trial visit’ to be sure that the home will be able to meet their needs EVIDENCE: The manager or head of care visits all prospective residents to complete a comprehensive pre-assessment, which includes any equality, and diversity needs. This information is used for the home to be able to ensure that it can meet all of the residents assessed needs. Where the resident is care managed a copy of the joint assessment is obtained. For private residents a report is requested from their G.P. or the hospital. A brochure for the home and the statement of purpose and service user guide giving full details of the facilities Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 9 on offer in the home is given to all prospective residents. All residents are issued with a contract. Prospective residents are invited to visit the home with their relatives or representatives for a look around and a cup of tea or coffee. This is followed by a day visit to give them the opportunity to have a further look around, to see the room that is available, and to join other residents for a chat and a meal. This helps them to assess whether the home is offering what they want. The first month of living in the home is classed as a trial period for all residents. A resident comment card included, ‘I came on a ‘trial visit’. This home does not offer the facility of intermediate care, which is a specialised service with dedicated accommodation, facilities, equipment and staff to deliver short-term intensive rehabilitation to enable people to return to their own homes. Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are met by the home supported by a team of health-care professionals. Residents are treated with dignity and their privacy is respected EVIDENCE: The home draws up an individual plan of care for each resident. The care plan is based on the information obtained in the pre-admission assessment. Care plans include health, personal care, equality and diversity needs and a variety of risk assessments. All care plans are reviewed monthly after discussion with the resident. Annual reviews also take place to include the resident and their relative or representative. Care plans have been improved during the past 12 Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 11 months to involve the residents and their families in the choices and lives of the resident, and to give more in-depth information to carers. The health care needs of the residents are met by the home supported by a multi-disciplinary health care team. Residents are able to register with the doctor of their choice and at present doctors from two surgeries visit the home. One doctor holds a fortnightly surgery in the home for any of his residents. Evidence was seen of contact with doctors, nurses, chiropodist, optician, and dentist. Hearing tests are arranged where necessary and the staff clean and maintain residents hearing aids. At the time of the inspection there were no residents with pressure area sores. However, the home has equipment available for use if any resident appears vulnerable to sores. At such times the district nurses are contacted and give support and guidance. All residents are weighed monthly. If a resident’s weight varies significantly a nutritional risk assessment is completed, a record is maintained of dietary intake, and the G.P. or dietician is consulted. Professional advice is sought for continence needs. Resident comment cards confirmed that residents always or usually receive the medical support they need. One included the comment, ‘I am answering on behalf of my mother who has been here 4 years. She has had bad periods regarding her health, and nothing has been too much trouble for the staff who always make sure of her comfort’. A resident said, “They called the doctor when I needed him”. The home has clear policies and procedures for the administration of medication. Some improvements are needed in the recording of medication, these were discussed with the manager and head of care during the site visit and a recommendation is made regarding this. All staff that administer medication have received training and medication administration witnessed was handled sensitively. It was observed that staff treat residents with respect. The home operates a key worker system enabling residents to be able to relate to and form a relationship with a named member of staff. Where residents share a room curtains are available to enable privacy when required. Resident comment cards confirmed that staff listen to and act upon what they say. Comments included, ‘sometimes they move away and that seems as though they hadn’t heard me. Apart from this, they are very good’ and ‘Staff are very kind and talk to us as Human Beings’. Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 1, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to maintain contact with their family and friends and to lead a life that meets their needs and expectations. They receive a varied and balanced diet. EVIDENCE: The home has recently employed a new activities co-ordinator. She has been talking to residents individually to find out what group and 1:1 activities they would like and is now organising a new programme of activities to meet their needs and preferences. The activities co-ordinator has attended training in ‘Life Plan Activities’, and the manager is currently trying to access a more in depth training course for her to attend. Current activities include music and movement, visiting musician, visiting hairdresser, walks, reminiscence, and manicures. A copy of the weekly activities programme is on display in the hallway. Outings are arranged about four times a year and have included trips Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 13 to the theatre, blossom tour and cream tea, and Hastings with fish and Chip lunch. Residents said, “I join in the activities”, “We go for lovely walks”, and “I enjoy the activities”. Comment cards included, ‘I cannot do any of the activities as I find it difficult to walk’. A member of staff said, “they go out on trips and have entertainment brought in for them”. The current residents religious needs are catered for by a weekly service. Four different denominations take it in turn to organise this. The local Priest also visits each week to see any of the residents who wish to speak to him. Currently residents at the home all come from Christian backgrounds but if there were a resident who required contact from any other faith the manager would support the contact. Residents are able to see their visitors at any time suitable for them. Visitors are made welcome and are able to make themselves and the resident drinks in the ‘coffee bar’ area. In addition to their own bedrooms there are a variety of sitting areas where residents can entertain their visitors. Residents said, “They make my daughter welcome”, and “My daughter may take me out”. Residents are encouraged to exercise choice over their lives. Choices include time of getting up and going to bed, what to wear, where to sit, who to socialise with, whether to take part in activities or not, and where and what to eat. A resident said, “We can sit where we want”. The home serves traditional home cooked meals. The menu shows a good variety of balanced meals with choices at all mealtimes, and a cooked breakfast option available once a week. There are occasional ‘themed’ evenings with refreshments and these have included cheese and wine, fireworks and hot dog and soup, and tea parties. The home has gained an award for Nutrition in the Elderly from the health service. If a resident does not like the choices available an alternative will be given on request. The cook confirmed that if residents want extra portions they only have to ask as there is always more available. Currently the only special diets needed are fat free and diabetic. If a soft diet is required this is served in separate portions to look as much like an ordinary meal as possible. Resident comment cards confirmed that most residents either always or usually like the food, with just one saying sometimes. A comment ‘Vegetables are overcooked. Meat often tough. Very little salad or fresh fruit’ was included on one form. This was discussed with the manager who confirmed that there is always fresh fruit available in the three lounges. Vegetables are cooked in the way that the majority wish but if they are overcooked for one person they only have to say and this will be addressed. Comments from residents on the day of the site visit included, “I like all the meals”, “We get well fed”, “I enjoy my meals”, and “I have put on weight since I moved in”. A visitor said, “They are well catered for”. Staff said, “I always like the food”, and “I like the food, and I am fussy”. Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know that their complaints and concerns will be listened to and acted upon. Residents are protected from abuse EVIDENCE: The home has a clear and accessible complaints procedure. A copy of the complaints procedure is clearly on display in the home. Comment cards confirmed that residents and relatives know how to complain and that the home responds appropriately to any concerns raised. One visitor comment card stated, ‘I have never had concerns about my mothers care so cannot comment on this’. The home has received 6 complaints in the last 12 months; one of these was initially submitted to the Commission who referred it to the home for investigation. All complaints were responded to within the appropriate timescale and were satisfactorily resolved. Where complaints are upheld they are dealt with quickly and procedures are put in place to prevent reoccurrence. The home maintains a register of all official complaints. All informal concerns raised are documented in the individual resident’s file. Residents commented, “I’m quite satisfied”, and “No complaints at all”. As Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 15 well as a complaint register the home keeps a ‘compliments’ file. Examples of compliments received included, ‘She was only with you a short time but she wrote to say she enjoyed sitting in the garden with 3 ex-servicemen’, and ‘Many thanks to you and your teams positive approach and for all you are trying to do for my dad’. Residents are protected from abuse. All staff have received training in the protection of vulnerable adults. No new member of staff is employed until a satisfactory check of the Protection of Vulnerable Adults register is obtained. The manager is prepared to make referrals to the Adult Protection team if this is necessary. The home does not handle cash for any of its residents. Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, & 25 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is well maintained, clean, and homely with spacious grounds to enjoy and bedrooms personalised to meet their needs. EVIDENCE: The home is situated in a large 2-storey detached building, in its own extensive and well kept grounds. There is level access for residents to gain access to the grounds. The home is well maintained. During the last year the main areas have been refurbished with new furniture and lighting has been provided. The lounges and corridors have been painted, and carpets and Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 17 curtains have been replaced. The entrance porch is due to be refurbished and decorated in the near future and a new security system will be fitted at that time. A resident comment card stated, “Walls and ceilings will be decorated this year (carpets all done before Christmas 2007)”. A visitor said, “It is very comfortable”. A link has recently been provided to the adjoining cottage, which has now been registered for an additional 5 residents. It is anticipated that this will be opened for use in March 2008. ‘The cottage’ will be used to accommodate residents who are more mobile as those living on the first floor will need to be able to climb the stairs. The main house has 2 shaft lifts to provide access to the upper floor areas. The fire panel is being moved and system updated to include ‘the cottage’. The home overlooks its own lake, where the residents can watch the wildlife. During the last year the garden furniture and sitting areas have been improved. Residents said, “some baby ducks were born the other day, I watched it happen”, “Nice gardens”, and “It’s a lovely setting”. Communal areas in the home include 2 lounges, a dining room, a large conservatory, and seating in the hallway. There is also a ‘coffee bar’ area where residents or their visitors can prepare themselves drinks at any time. The conservatory is a bright airy room, which is a little cooler for those residents that don’t like to be too warm. When ‘the cottage’ is brought into use there will be an additional lounge/conservatory, a lounge/dining area, and a kitchen for preparing breakfasts, snacks and drinks. All of the furnishings and fittings in the communal rooms are domestic in character and suitable to meet the needs of the residents. During the past year 50 of the bedrooms have been refurbished. All resident’s bedrooms are nicely decorated and furnished. Curtains are available for privacy in shared rooms. The majority of the bedrooms have en-suite facilities some with sit in baths. For those rooms that do not have private facilities there are adequate bathroom and toilet facilities close by. Residents are able to bring their own possessions to personalise their rooms. Residents comments included, “I like my room, I’m at the top”, “I have asked for a ground floor room with en-suite when one is available. Because one of my radiators is linked to the room next door I can’t alter the temperature as I would like”, and “I’ve got my own bits and pieces in my room”. The home is kept clean and hygienic and is generally free from odours. Resident comment cards confirmed that the home is always or usually fresh and clean. Residents said, “It is always clean”, and “There are always workers cleaning up”. Since the last inspection an additional domestic has been employed and all cleaning staff have been trained in Infection control and NVQ 2 in cleaning. There was a requirement on the last report about using the laundry for hairdressing and this practice has now stopped. On the day of the site visit the kitchen was being closed during the afternoon to have a professional deep clean. The laundry is equipped with a washing machine with Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 18 an infection control programme. Infection control procedures in the home are sound and they have carried out an infection control audit. There is a sluice fitted with a macerator in the home. Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 19 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents are cared for by a dedicated team of staff who are trained to meet their needs. EVIDENCE: The home employs staff in sufficient numbers to meet the resident’s needs and staffing levels have improved during the past year. When ‘the cottage’ is opened the numbers will be further increased by one on each shift. In addition to carers there are domestic staff, cooks, kitchen assistant, and the manager and administrator. There is a low staff turnover in the home with some staff having been working in the home for a number of years. The home does not employ agency staff as the existing staff and the one bank carer cover for holidays and sickness giving better continuity of care for the residents. The home is proactive in ensuring that all staff undertake NVQ qualifications. Currently 100 of care staff have either trained or are training to NVQ at Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 20 Level 2. Staff said, “I have NVQ 2 in care”, and “I have NVQ 2”. 2 carers are training towards NVQ 2. The head of care has attained her NVQ Level 3 and the other seniors are just starting this training, one said, “I am starting Level 3 in March”. One member of staff has also started her Level 4 and said, and “I am doing NVQ 4”. Domestic and kitchen staff are also encouraged to do their NVQ in appropriate subjects. One said, “I have NVQ 1 and 2 in Domestics”. The home has sound recruitment procedures in place. No new member of staff is employed until a Criminal Records Bureau check has been submitted; a satisfactory check of the Protection of Vulnerable Adults Register has been received; and 2 satisfactory references are received. The manager is updating staff files to include a full employment history. Residents have the opportunity to meet prospective new staff at a trial session and some are keen to let the manager know what they think. All new staff have induction training to Skills for Care specifications. Each member of staff has an individual training program. Training needs are organised following their supervision or appraisals or on request. All staff are trained in the mandatory subjects and the Protection of Vulnerable Adults. All staff who assist with medication have received training. The manager and all senior carers are fully qualified first aiders, the rest of the staff have attended a appointed persons first aid course. The manager and a senior are booked to attend an Safeguarding Adults seminar run by the Tizard Centre of the University of Kent. The domestic staff have recently attended a 14-week course on infection control, COSHH and RIDOR. 5 staff are booked to attend a training session on infection control organised by the Health Protection Agency. The manager is currently accessing advanced training in activities for older people for the activities co-ordinator. Staff have also attended training in Challenging Behaviour, Dementia, Dying, Loss and Bereavement, and Catheter Care during the past year. Resident comments about the staff included, “They are very helpful”, “They look after us well”, “The staff are lovely, they never seem to stop”, and “The staff look after me well”. A visitor commented, “The staff are very helpful and jolly”, and “staff are polite”. Staff comments included, “It’s the happiest I’ve been in a job”, “All the staff get on well”, “I love it”, and “I am really, really happy”. Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 21 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, 35, & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of the residents. Residents and staff health, safety and welfare are protected EVIDENCE: The manager has worked in the home for over 25 years and has been the Registered Manager for the last 8 years. She has an NVQ Level 5 in Operational Management and is an NVQ Assessor. She does all of the mandatory training with her staff and also undertakes a variety of other Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 22 training. She has sat on the executive board of the Kent Care Homes Association for nearly three years. This helps to keep her up to date with changes in regulations policies and procedures and latest good practice. The home was originally owned by the manager’s family but was sold two years ago and she has a good working relationship with the new providers. The manager encourages an open door policy for residents and staff and is actively involved in the training of staff and staff supervision. There are clear lines of accountability both between manager and staff, and manager and providers. The atmosphere in the home is relaxed and friendly. A resident said, “The manager is nice”. Staff commented, “The manager gives us support”, “She is certainly supportive”, and “The atmosphere is good”. The home has developed a system of quality assurance. Questionnaires to gain their views are sent to residents, residents family, staff, and visiting professionals annually. An analysis of results is produced and any suggestions or comments are investigated and actioned where possible. An audit tool is in place for regular audits. The home holds the Investors in People award and has annual quality inspections from a Kent Care Homes Association quality inspector. The home gained a gold star from Environmental Health, and an award for Nutrition in the Elderly from the Health Service. The provider makes regular visits to the home and documents monthly Regulation 26 reports. Resident meetings are held every 2-3 months and the manager is currently trying to get one of the residents to chair these meetings. Informal staff meetings are held daily. Formal meetings for seniors are held monthly and for all staff three times a year. The home has a written business plan as well as a yearly quality improvement plan. The manager completed the homes AQAA (Annual Quality Assurance Assessment) for the Commission and returned this a week before it was due. Information given in this document was clear and comprehensive and included details of how the service meets any equality and diversity needs that the residents or staff may have. It also demonstrates that the manager is aware of the need to provide value for money and has identified improvements that could be made to the service. The home does not hold any monies for residents. All transactions are completed and invoiced to the resident or their representative. The health, safety and welfare of residents and staff is promoted and protected. All staff have regular updates of mandatory health and safety related training. The manager, or a senior, carries out daily checks of the environment. The home has Environmental Health checks and checks from a Health and Safety professional. All testing of appliances and equipment is up to date. Recording of accidents is in line with current good practice. Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 23 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 4 X 3 X X 3 Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 24 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. Refer to Standard OP9 Good Practice Recommendations The home should improve its recording of drugs received and disposed of. Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Capel Grange DS0000065623.V357939.R01.S.doc Version 5.2 Page 26 - 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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