Care Home: Capwell Grange Nursing Home

What the care home does well The home understands the importance of having enough information when choosing a care home. Pre-admission documentation was in place, and was being completed appropriately. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been written in consultation with individuals and their representatives. Medications were stored and administered correctly. Residents dignity was considered. For example people wore their own clothes and looked clean and smart and those that had chosen to stay in their room, or in bed were dressed appropriately. Also people were spoken to in a polite and respectful manner by the staff, and it was clear that people had been asked about the name by which they wished to be referred, as this was recorded in their care plan. When residents were first admitted, families were encouraged to help prepare a map of life, and lifestyle profile which included information about their families and their personal likes and dislikes. The staff could use this information to help build a profile of social interactions or activities that the individual may particularly enjoy or benefit from. Visitors could visit at any time that suited the person they were visiting. The home had a complaints policy, which was on display and easily accessible to residents and visitors to the home. This document detailed expected timescales for responses, and guidance for any complainant that remained dissatisfied with the investigatory outcomes. All of the houses were clean and tidy A variety of training was offered to all of staff to ensure that collectively, they had the skills and experience, to meet the needs of the people living at the home. Recruitment procedures were fully adhered to so that residents were protected. The registered manager had the required qualifications and experience and was competent to run this large home. She was supported by the organisations strategic planning and auditing processes What has improved since the last inspection? Staff were now ensuring that residents weight gains and losses were recorded and that if there was a significant weight gain or loss the correct advice and treatment was sought from the appropriate healthcare professionals. The company had held a successful staff recruitment drive, including a review of pay scales to fill care staff vacancies. What the care home could do better: The management are aware of the need to refurbish and redecorate many areas of the home. This should include the laundry area, which is currently not part of the maintenance plan. We would ask that staff are reminded about feeding clients, perhaps using role play so that understand what it is like to be totally dependent on someone for this. CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Capwell Grange Nursing Home Addington Way Oakley Road Luton Bedfordshire LU4 9GR Lead Inspector Sally Snelson Unannounced Inspection 18th March 2009 09:45 X10029.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 Capwell Grange Nursing Home DS0000017668.V374650.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 and Care Homes for Adults 18 – 65*. 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. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Capwell Grange Nursing Home Address Addington Way Oakley Road Luton Bedfordshire LU4 9GR 01582 491874 01582 564225 tolladam@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd 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) Mary Tolladay Care Home 146 Category(ies) of Dementia - over 65 years of age (60), Mental registration, with number disorder, excluding learning disability or of places dementia (8), Mental Disorder, excluding learning disability or dementia - over 65 years of age (8), Old age, not falling within any other category (120), Physical disability (34) Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can accommodate a maximum of 146 service users of either sex. No one falling into the category of mental disorder (MD) or (MD)(E) may be admitted to the home where there are 8 persons, in the age range of 55 in these categories already accommodated within the home. No person under the age of 55 years can be accommodated in the category of MD. No one under the age of 65 years can be admitted to the home where there are 34 persons already accommodated in the home. Service users who are over the age of 60 years and who have dementia (DE) can be admitted to Hatley Unit. 24/01/2008 3. 4. 5. Date of last inspection Brief Description of the Service: Capwell Grange Nursing Home is a complex comprising of a central two-storey building and five single-storey houses. The central building provides accommodation for administration, reception, and services including laundry, catering, a staff room, staff training areas and a visitors suite. There is ample parking for staff and visitors. Two of the houses, Milliner and Hatley provide care for elderly service users with a diagnosis of dementia. Two others, Fidora and Bonnetti accommodate frail residents who require both nursing and social care. These four houses are all registered for 30 service users. The fifth house, Mitre, is registered for 26 service users under the age of 65 years with a physical disability. Staff providing care are qualified nurses and care assistants supported by ancillary staff. Each house has a small quiet lounge, which in some houses is used as a service user smoking area, an open plan lounge with a dining area, and a conservatory. There is access to the well-tended gardens via the entrance or the lounge. The service users individual accommodation has en suite facilities and suitable furniture and fittings. All rooms have an emergency call system. There are separate toilet and bathing facilities available with access to aids for assistance. Main meals are prepared centrally and each house has a small kitchen for preparing and serving food and drinks. The weekly fees range from £445.00 to £978.50 a week, the fees are Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 5 dependent on the funding source and the specific needs of individuals. Information about the home and the services provided is available within the homes statement of purpose and service users guides, and these documents are located within the main entrance of the home and within the entrance lobby of each of the individual houses. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is based upon outcomes for people living at the home and their views of the service provided. This visit was unannounced and focused on the ‘key standards’ under the National Minimum Standards (NMS) and the Care Standards Act 2000 for homes providing care for older people (OP) and younger adults (YA). The inspection took place over a period of five hours from 09.45 hrs on the 18th March 2009. Sally Snelson and Louise Trainor undertook the inspection so the home received a ten-hour inspection. The care needs of five people living at the home were looked at in depth, this involved looking through written information available on their care, such as their care plans (a care plan sets out how the home aims to meet the individuals personal, healthcare, social, emotional and spiritual needs). With an aim to establish how residents care needs were supported, time was spent speaking with people living at the home, staff and visitors and observations were made on the care practices within the communal areas of the home. During the inspection we spent the majority of the time on Fidora and Hatley, with a visit to Mitre. The homes policies and procedures and records in relation to staff recruitment, complaints, and the general maintenance and upkeep of the home were sample checked, and a partial tour of the building was conducted. To further assist in gaining the views of people who live, work and visit the home on a personal and professional level, CSCI circulated a selection of ‘have your say’ satisfaction surveys for completion. Six residents surveys and seven staff surveys were returned to CSCI prior to the visit-taking place. Comments received from the surveys were considered. These had been returned to us sometime in advance of the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 7 What the service does well: The home understands the importance of having enough information when choosing a care home. Pre-admission documentation was in place, and was being completed appropriately. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been written in consultation with individuals and their representatives. Medications were stored and administered correctly. Residents dignity was considered. For example people wore their own clothes and looked clean and smart and those that had chosen to stay in their room, or in bed were dressed appropriately. Also people were spoken to in a polite and respectful manner by the staff, and it was clear that people had been asked about the name by which they wished to be referred, as this was recorded in their care plan. When residents were first admitted, families were encouraged to help prepare a map of life, and lifestyle profile which included information about their families and their personal likes and dislikes. The staff could use this information to help build a profile of social interactions or activities that the individual may particularly enjoy or benefit from. Visitors could visit at any time that suited the person they were visiting. The home had a complaints policy, which was on display and easily accessible to residents and visitors to the home. This document detailed expected timescales for responses, and guidance for any complainant that remained dissatisfied with the investigatory outcomes. All of the houses were clean and tidy A variety of training was offered to all of staff to ensure that collectively, they had the skills and experience, to meet the needs of the people living at the home. Recruitment procedures were fully adhered to so that residents were protected. The registered manager had the required qualifications and experience and was competent to run this large home. She was supported by the organisations strategic planning and auditing processes. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 8 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. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5,6. Older people People who use this service experience good quality outcomes in this area. The home understands the importance of having enough information when choosing a care home. Pre-admission documentation was in place, and was being completed appropriately ensuring that staff were able to meet the needs of any prospective residents. We have made this judgment using a range of evidence, including a visit to this service. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 11 EVIDENCE: The home had a Statement of Purpose that included all the required information and was regularly updated and reviewed. We were sent a copy of this document as changes were made to it. There was also a variety of information about the home that was made available to those living at Capwell Grange and those making enquiries about the home. Information about the home and the services provided was available within the main entrance of the complex and within the entrance lobby of each of the individual houses. Each resident had a contract, a copy of which was stored securely in the general office away from his or her care records. The contract detailed how the fees were broken down. The contract ensured that a resident’s initial period of stay was a trial period. During the inspection we did not speak to any residents who could remember making a choice to enter the home. However one resident told us, “My daughter choose this room for me, lovely isn’t it”. The manager confirmed that residents, or someone on their behalf were encouraged to visit the home before making a decision about admission. Within the care files there was a record of a pre-admission assessment. This assessment identified the initial needs of the residents and had a space for them to be assessed again within 2-4 hours of admission. The pre-admission assessment identified any specialist equipment that would be needed so it could be secured before admission. The home did not offer intermediate care. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Older people People who use this service experience good quality outcomes in this area. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been written in consultation with individuals and their representatives. Medications were stored and administered correctly. We have made this judgment using a range of evidence, including a visit to this service. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 13 EVIDENCE: We looked in detail at the care plans of five residents across two units, Fedora and Hatley. The plans had been written in explicit detail and ensured that the reader was clear about how to provide the required care. Each plan identified the problem, the objectives, the goal and the action. For example a catheter care plan included details of when the catheter had been inserted, when it needed to be changed and the routine care needed. In Hatley House, where cognitive impairment and dementia affects the majority of the residents, care plans were in place to address, memory and behavioural aspects of care. These were supported by ‘rating scales’ and behavioural charts, all of which were being reviewed on a monthly basis. The care plans and the associated risk assessments were reviewed monthly and we were aware that changes were made as care needs altered. Residents, and or their families, were encouraged to read the care plans and to be part of the care planning process. This was reflected on agreement forms signed by family members. In the last report it was stated that the home were experiencing difficulties in registering new residents with local general practitioners, and difficulties in obtaining sufficient supplies of medication, especially when a residents was discharged from hospital into the home. The manager confirmed that this had been rectified, by consultation with the Primary Care Trust (PCT) and where it was not possible for a resident to retain their family GP each house had been allocated a GP practice to contact in the first instance. People using the service told us, and the records confirmed it, that GP’s and other health professionals were called when required and were also used to offer advice and support. We looked at the care file of one resident who had had eight visits from various multi-disciplinary staff since his admission less than one month previously. We noted that people were wearing their own clothes and looked clean and smart. Those that had chosen to stay in their room, or in bed were dressed appropriately. People were spoken to in a polite and respectful manner by the staff, and the interaction between the staff and the residents was a pleasure to observe. It was clear that people had chosen the name by which they wished to be referred, and this was recorded in their care plan. The medication storage and administration records and medication held within the home including those, which were classed as controlled drugs, were sample checked in two of the units. The medication administration records Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 14 (MAR) sheets, the controlled drugs register and the records of medication returns were all in good order. We chose resident’s MAR sheets at random, and checked the corresponding stocks. All medications were clearly signed into the house, the details of medication carried forward each month were clear, and all refusals and disposals were clearly recorded. All stocks that we checked reconciled accurately. Where residents had ‘chronic conditions’, such as diabetes, there were detailed information sheets attached to the MAR sheets, these identified any contraindications of the condition, how to recognise them and how to manage them. Staff also retained the pharmaceutical leaflets from the medications to provide information about possible side-effects or contra-indications. Since the last inspection the local PCT had commissioned two beds on Fidora for people requiring palliative care. The staff from Fidora had undertaken additional training about end of life care and were aware of current best practices. One nurse said, “we are proud of our management of pressure areas and none of our palliative residents have developed pressure sores”. At the time of the inspection the home was not using Liverpool care pathways but staff were aware of the need to ensure that people had the opportunity to influence their end of life and be free of pain, by using similar documentation unique to the company. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Older people People who use this service experience good quality outcomes in this area. The service had a strong commitment to ensuring residents maintained the personal relationships that were important to them. Suitable and meaningful activities were encouraged, and individual’s were assisted and supported to make personal choices. We have made this judgment using a range of evidence, including a visit to this service. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 16 EVIDENCE: Each of the five houses employed it own activity co-ordinator to plan and coordinate the activities for that house. It was noted that on Fidora the activity co-ordinator involved people as they came into the lounge in whatever was going on. This allowed all the care staff to support residents with their personal care. This unit had been decorated for the St Patrick day celebrations that had taken place the day before the inspection. When residents were admitted, families were encouraged to help prepare a map of life, and lifestyle profile which included information about their families and their personal likes and dislikes. The staff could use this information to help build a profile of social interactions or activities that the individual may particularly enjoy or benefit from. There was a large activity board situated in the main corridor. This identified what activities were available each day of the current week and at what time. There was also a board reminding residents of the date, the weather conditions, and the names of the staff team on duty for each shift for the day. Visitors could visit at any time that suited the person they were visiting. We noted that the staff had a good relationship with visitors and would spend time with them. On one unit a visitor had stayed continually with a resident during their stay, and staff had supported this. On the other unit we spoke to another visitor, who was clearly very involved with his wife’s care, and spent most meal times with his wife. This had helped to improve her appetite and consequently her general health. This relative also told us how he and other relatives support the home. One example was the ‘make over’ in the garden, which now provides a pleasant area to spend time weather permitting. It was apparent that people choose when to get up and when and where to have their breakfast. The last breakfast we saw being served was at 10.40am. This home offered a variety of nutritious meals that were presented and served in an appetising way. On the day of the inspection there was a choice of roast beef and Yorkshire pudding or bacon and onion flan each with a selection of vegetables, followed by mincemeat tart or ice cream. The kitchen also provided occasional meals for people from other cultures who were happy to eat English food but enjoyed their own foods at times. Staff were noted to be assisting individual residents with their meals in a dignified and unhurried manner. Mealtimes were being promoted as a social and relaxed occasion. On the whole staff supported residents at mealtimes in an appropriate and unhurried way. However we did see one carer feeding yoghurt to a resident Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 17 using a dessertspoon. When challenge he had not thought of using a smaller spoon as he believed a teaspoon was only for stirring a cup of tea. The dining tables were attractively prepared for the mealtime with napkins, flowers cruets, and drinking glasses. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Older people. People who use this service experience good quality outcomes in this area. The complaints procedure was supplied to everyone living in the home. Staff working at the home understood the procedures for safeguarding, and knew when incidents need to be reported externally. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home had a complaints policy, which was on display and easily accessible to residents and visitors to the home. This document detailed expected timescales for responses, and guidance for any complainant that remained dissatisfied with the investigatory outcomes. It is also produced and displayed in pictorial format, so that residents with cognitive impairment would understand it more easily. We viewed the complaints file. The home had received several concerns / complaints since the previous inspection. Those that we looked at in detail had all been managed appropriately, and all response letters and the actions taken Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 19 as part of the investigations were filed for inspection / audit purposes. The manager believed that her open and transparent style of management, encouraged people to speak up with they had any concerns. Staff in each house had received training about dealing with initial complaints. They were then responsible for ensuring the manager was made aware so that any concern or complaint was logged centrally. Relatives that we spoke to during this inspection, were satisfied that the any concerns they raised were addressed efficiently and effectively. Safeguarding issues were also clearly recorded, and being reported appropriately. We had been made aware of all referrals made since the previous inspection, and all had been managed appropriately. Documentation indicated that the manager liaises with the safeguarding team as and when necessary, and the home is embracing the Mental Capacity Act including the Deprivation of Liberty. The whistle blowing procedure is also clearly displayed. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Older people People who use this service experience adequate quality outcomes in this area. The home was clean and tidy, but all had areas that needed refurbishment and decorating. This was planned for the very near future. We have made this judgment using a range of evidence, including a visit to this service. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 21 EVIDENCE: At the start of the inspection the manager told us that it was expected that the refurbishment of the whole site, something that had been on the agenda for the last two to three years, was due to commence in approximately six weeks time. The manager had planned the order in which the work was to be carried out, according to the current state of each house. However despite this all the houses were being kept clean and tidy and free from offensive odours. As expected there were carpets that needed changing, curtains that needed replacing, wardrobes that were old and paintwork that was very scuffed. These areas had all been highlighted in the homes quality surveys and would all be done as part of the planned refurbishment. Therefore no requirement or recommendations will be made in relation to the communal and individual environmental areas of the home, despite there being some shortfalls. We would however like to commend the murals, particularly throughout Hatley House. These have been done by a member of staff and beautifully portray various scenes, which reflect different periods of time from the ‘war years’ to the ‘rock n roll days’. We hope these will be carefully preserved during any redecorating. However we were disappointed that while touring the building we noted how dusty and dirty the laundry room was, despite the staff’s attempts to wash the walls and keep the area clean. We were told that this area was not included in the planned refurbishment. Therefore a recommendation will be made that consideration is given to this area. The site had a number of small garden areas and the home employed a person to do the garden. Each house had an area for residents to sit and each had been planted to their own taste. One house had introduces an area where relatives could have a plaque, or area dedicated to a loved one that had passed away. Relatives were also encouraged to participate in projects in the garden, and the husband of one resident had installed a bird table, directly outside his wife’s bedroom window. This has been successful in attracting visiting birds and consequently bringing pleasure to everyone who used the garden. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Older people. People who use this service experience good quality outcomes in this area. A variety of training was offered to all of staff to ensure that collectively, they had the skills and experience, to meet the needs of the people living at the home. Recruitment procedures were fully adhered to so that residents were protected. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: At the time of the inspection the manager informed us that the home had vacancies for two qualified and three care staff. Until recently she had been Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 23 able to cover any vacancies with staff agreeing to do some extra shifts. However over the last few months because of staff taking holidays at the end of the year, and the suspension of two staff pending investigation, there had been a need to use agency staff. The home used one agency and believed that the agency tried to send the same staff wherever possible. The staff team had altered a lot when the manager first took up post almost three years ago, but it was now becoming established. Some staff had worked at the home since it opened 13 years ago. Many of the staff talked to us about the improvements to the home over the past two or three years and the positive support of the manager. Each house was responsible for its own off-duty and it was expected that there would be seven staff on duty in the morning, six in the afternoon and four at night. Each house had a minimum of one qualified nurse on duty for each shift, but there were often two or three. The staff that we spoke to during this visit were confident and competent in their roles, and were able to talk in depth about individual residents needs and the care that they required. Training records indicated that staff attended a variety of mandatory training, which the unit managers ensured was kept updated by keeping a training matrix for each staff member on each unit. We noted that the training matrix detailed mandatory training and did not consider some of the specialist training we would expect to see. For example staff that were regularly caring for people with diabetes, or those being feed via a percutaneous endoscopic gastrostomy (PEG), would have some training in these areas. By talking to staff we were aware that this was being done, and that the home had trained many of the staff to be train the trainers (staff that had been trained to pass on their knowledge to others) but there was not always certificates to support this. We examined the personal files of four members of staff, two who had yet to take up their posts. All contained fully completed application forms and appropriate references. Criminal Record Bureau (CRB) checks had been carried out on all staff, and home office paperwork and checks on nurse’s registration updates were present where required. The home manager made the decisions about recruitment but could ask for human resource (HR) support for any queries. The manager told us that any student visas and some other documentation were routinely sent to HR for checking. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 25 31,32,33,35,36,37,38. Older people. People who use this service experience good quality outcomes in this area. The manager had the required qualifications and experience and was competent to run this large home. She was supported by the organizations strategic planning and auditing processes. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager had taken over the management of the home almost three years previously and had worked hard with the company and external organisations to make the necessary changes to the home. She said to us, “this is a big home and things have gone wrong, and will go wrong, but I believe in being open with everyone so that things can be sorted out”. We believed that this demonstrated a transparent style of leadership. On the day of the inspection the company’s quality manager was visiting the home. She would visit regularly and support the manager, and qualified staff who were responsible for the individual houses, by auditing various aspects of their work. As an organisation BUPA regularly reviewed and audited the quality of the care they provided. The manager had recently received the 2008 quality audit report and was actioning the identified areas for improvement. It was this document that had identified the decrease in the customer satisfaction with the environment, over the past few years. The home did not hold individual amounts of cash for residents, but if a resident or a family wanted to have money held on their behalf, this was banked and an electronic account set up. Money could be requested and was readily available via the petty cash. We looked at the staff supervision records on each of the houses that we visited. All records were up to date and indicated that staff were receiving supervision at least every other month as required. We looked at health and safety documentation, including the fire log and maintenance book. There was evidence to indicate that fire call points and the emergency lighting were being tested on a regular basis, and that fire drills were carried out periodically. Maintenance issues were being addressed in a timely fashion. Capwell Grange Nursing Home DS0000017668.V374650.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 3 2 3 3 3 4 X 5 3 6 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 3 11 3 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 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 3 33 3 34 X 35 3 36 3 37 3 38 3 Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP15 OP26 OP27 Good Practice Recommendations Staff should consider how they feed those residents who need this support. Consideration should be given to the redecoration of the laundry area. Staff training records should clearly indicate that the staff team have the necessary qualifications and training to care for the residents. Capwell Grange Nursing Home DS0000017668.V374650.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Capwell Grange Nursing Home DS0000017668.V374650.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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