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Inspection on 12/07/05 for Astley Grange Nursing Home

Also see our care home review for Astley Grange Nursing Home for more information

This inspection was carried out on 12th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home, and no service user is admitted without having his/ her needs assessed. The menus offered variety and choice, and a service user commented on how good the food was, and that they had no grumbles. The home is also in a good state of repair and decorative condition, and service users individual needs are met in a comfortable and homely way.

What has improved since the last inspection?

New service users have a full assessment of their needs by people trained to do so, prior to moving into the home, and the movement and handling needs of the service users are also included in their plan of care.

CARE HOMES FOR OLDER PEOPLE ASTLEY GRANGE Woodhouse Hall Road Woodhouse Hill Fartown Huddersfield Lead Inspector Karen Summers Unannounced 12 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Astley Grange Nursing Home Address Woodhouse Hall Road Woodhouse Hill Fartown Huddersfield 01484 428322 01484 451440 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Operations Limited Mr Clinton K Taylor Care Home with Nursing 40 Category(ies) of Care Home with Nursing - 40 places registration, with number of places ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 18th October 2004 Brief Description of the Service: Astley Grange provides both personal care and nursing care to service users of both sex aged 65 years and over. The home is a purpose built, and is situated in a quiet cul de sac adjacent to Fartown High School. The accommodation is over three floors with a lounge area on each, and the dining room is situated on the middle floor. There are 32 single rooms and 4 double rooms. The grounds are an array of colour, with well kept flower beds and hanging baskets. Astley Grange is close to local amenities such as shops, churches and is on a bus route. The home also has its own minibus, which is used for social outings on a regular basis. ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unanounced inspection at Astley Grange on Tuesday 18th July 2005, commencing at 9.30am, and the duration of the inspection was 5.5 hours. Mrs K Summers, Regulation Inspector was accompanied by Mrs T South, Regulation Inspector, and the Manager, Mr C Taylor was also present at the inspection. The following methods have been used in the production of this report: sampling of records, care plans, individual discussion with 9 service users, the administrator, tour of the premises and document reading. What the service does well: What has improved since the last inspection? What they could do better: The care documentation is comprehensive however care must be taken to ensure that all the needs of the service user has been identified and met. The nurses should also ensure that there is evidence that they have honoured their duty of care and that any actions or omissions on their part have not compromised the service users safety in any way. The emergency lighting should be tested/ recorded monthly. Please contact the provider for advice of actions taken in response to this ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 5 No service user moves into the home without having had his/ her needs assessed and been assured that those needs will be met. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. EVIDENCE: Prospective service users and their relatives are encouraged to have a look around the home, and spend some time there before deciding to move in. Once the manager is satisfied that they can meet the service users needs a letter is sent offering them a place at the home. All service users are admitted following a full assessment undertaken by people trained to do so, and to which prospective service user, his/ her representative (if any) and relevant professionals have been party. Each service user then has a plan of care for daily living, and longer-term outcomes based on the pre admission assessment. ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 - 10 Progress has been made in the development of the care documentation however, when documentation relating to the service users dietary needs are not kept up to date, their health could potentially be at risk. EVIDENCE: Care plans were comprehensive and set out in detail the action that needs to be taken by care staff, to ensure that all aspects of the health and social care needs of the service users are met. The plans included risk assessments that had been reviewed once a month. The daily record was also comprehensive and included the outcome of the care delivered in relation to the health care needs however; the record did not show in sufficient detail what the service user did socially. The care plans had also been reviewed monthly; unfortunately the corresponding feeding regime chart for one service user had not been amended when the care plan had been reviewed. When a service user’s plan is reviewed the corresponding documentation must also be updated. One of the service users who were spoken with said that the staff were kind, and that they were always there to help. Staff were also seen to respond to service users needs in a respectful, and kind and caring manner. ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 - 15 Without the interests of the service user recorded, there is no evidence to suggest that the lifestyles experienced in the home matches their expectations and preferences, and satisfies their social, and recreational interests and needs. A variety of meals are offered that take into account the likes and dislikes of the service users. EVIDENCE: There is a dedicated activities person that works four half days a week, and the carers also organise activities. Events/ photographs had been recorded in a file and they were informative however; the activities that that service user is involved in on a daily basis should also be recorded in their individual files together with their interests and hobbies. The menus offered variety and choice, and the food preferences and diets were also taken into consideration. A service user commented on how good the food was, and that they had no grumbles. ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not assessed on this occasion. ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 The home is in a good state of repair and decorative condition, and service users’ individual needs are met in a comfortable and homely way. The premises are clean and systems are in place to control the spread of infection. EVIDENCE: Service users are encouraged to bring small items of furniture and memorabilia into the home, and a number of bedrooms had been individualised with belongings, and reflected the personalities and tastes of the people living there. Carpets have recently been replaced in the communal areas, and the home is in a good state of repair and decorative condition. The grounds are an array of colour, with well kept flower beds and hanging baskets. Bathroom 51 – the privacy lock would not work and therefore should be repaired/ replaced. The hand wash towel in the laundry room should be replaced with paper towels. The premises are kept clean and staff have training in infection control. ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 30 The staffing levels and skill mix were sufficient to meet the number and needs of service users. Staff are also trained and competent to do their jobs. By the end of December 2005, there will be a minimum ratio of 50 of care staff having an NVQ level 2 or equivalent. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users in the home. 21 of care staff have achieved an NVQ level 2, or equivalent, and a further 18 staff have commenced the training. The company plan to meet the recommended standard of 50 of staff having the qualification by the end of December 2005. ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35 & 38 The home is run in the best interest of service users, and the registered manager ensures so far as is practicable that the health, welfare of service users and staff are promoted and protected. When the emergency lighting is not adequately maintained service users would be further at risk in the event of a fire. EVIDENCE: Mr Taylor, the manager, is a registered nurse and has attained an NVQ 4 in management. Feedback is actively sought from service users and their family and friends, and health care professionals about services provided through anonymous satisfaction questionnaires, and the results are circulated in a news letter, which is distributed approximately three monthly. Service users financial accounts are satisfactorily maintained. Staff have attended fire drills and lectures, and the handyman tests the fire alarms weekly, and the emergency lighting monthly, however when the handy man recently was on leave the emergency lighting was not tested. The lighting should be tested monthly. ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x 3 x x x x 2 ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 16 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15.-(2)(b) Requirement When a service users plan is reviewed the corresponding documention must also be updated. (i.e. - the feeding regime documentation should also be updated.)You are also advised to refer to the Nursing & Midwifery Councils Guidelines for records & record keeping. Legal Matters & Complaints. Timescale for action At the time of the evaluation. 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 7.2 & 12.3 Good Practice Recommendations * When a service user refuses to have the care that has been identified, then his/ her wishes, and the action taken, should be recorded. You are advised to refer to the Nursing & Midwifery Councils Guidelines for records & record keeping. Legal Matters & Complaints. * The outcome of the social care needs should be recorded in more detail. * The information about hobbies/ interests should be recorded for each service user. Please refer to the Nursing & Midwifery Council Guidelines for records & record keeping Content & Style - records should: * be accurately dated, timed, & SIGNED (Not all J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 17 2. 8 ASTLEY GRANGE 3. 4. 5. 6. 19.1 26.3 28.1 38.2 records had been signed.) Bathroom 51 - The privacy lock would not work. The lock should be repaired/ renewed. Laundry, hand washing facilities - In the interest of infection control, paper towels should be used in this area. A minimum ratio of 50 trained members of care staff to achieved an NVQ level 2 or equivalent, by 31st December, 2005. Emergency lighting should be tested monthly. ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 18 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI ASTLEY GRANGE J51J01_s1108_Astley Grange_v220644_120705.doc Version 1.40 Page 19 - 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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