Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 08/06/06 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 8th June 2006.

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

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

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. One of the service users who were spoken with confirmed that they had visited the home before moving in. Care records were of a good standard, and the health, personal, and cultural needs were all taken into account when planning the service users care. The two questionnaires returned from the doctors stated that staff demonstrate a clear understanding of the care needs of service users, and that they are satisfied with the overall care provided to service users within the home. One service user said that she was very happy living at the home, and that staff were kind. A variety of meals are offered that take into account the likes and dislikes of the service users and their religious and cultural needs. A service user confirmed that the home always provide their food of choice in relation to cultural needs, and a service user questionnaire stated that they always like the meals at the home. 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?

Care records have greatly improved since the last inspection, and staff should be complimented on their hard work in updating the documentation, which was of a good standard. Staff have had update training which included; abuse awareness, movement and handling, and fire, and further dates have been arranged to continue the process. Appropriate records are now held for service users finances. Mrs Moore, operations manager, held a relatives meeting at the end of May, and minutes were written. She also plans to continue the meetings on a regular basis, to enable relatives to air their views, and also keep them up to date with any change at the home.

CARE HOMES FOR OLDER PEOPLE Astley Grange Nursing Home Woodhouse Hall Road Woodhouse Hill Fartown Huddersfield West Yorkshire HD2 1DJ Lead Inspector Karen Summers Unannounced Inspection 8th June 2006 08:45 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 Astley Grange Nursing Home DS0000001108.V290627.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. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Astley Grange Nursing Home Address Woodhouse Hall Road Woodhouse Hill Fartown Huddersfield West Yorkshire HD2 1DJ 01484 428322 01484 451440 astleygrange@schealthcare.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) Southern Cross Operations Limited Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named service user aged under 65 years - category PD One named service user aged under 65 years Date of last inspection 8th November 2005 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 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 flowerbeds 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. Fees at the home start at £ 332.98 - £493.84 per week. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a key inspection, which included an unannounced site visit on the 8th June 2006, and the duration of the inspection was 8 hours. There were 28 service users in residence on the day. Mrs Pauline Moore, operations manager, was present throughout the inspection. The following areas were looked at and have been used in the production of this report; a sample of records, care plans, medication, individual discussion with five service users, one relative, two members of staff, tour of the premises and document reading. To reflect the views of those who use the service, satisfaction questionnaires were sent to: 6 service user, 4 were returned; 6 relatives, 3 were returned, 2 GP practices, both were returned. No questionnaires were returned from the district nursing team. The inspector would like to thank those who contributed to the inspection process, and also thank Mrs Moore, her staff, service users and their relatives, for their time and hospitality on the day of inspection. What the service 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. One of the service users who were spoken with confirmed that they had visited the home before moving in. Care records were of a good standard, and the health, personal, and cultural needs were all taken into account when planning the service users care. The two questionnaires returned from the doctors stated that staff demonstrate a clear understanding of the care needs of service users, and that they are satisfied with the overall care provided to service users within the home. One service user said that she was very happy living at the home, and that staff were kind. A variety of meals are offered that take into account the likes and dislikes of the service users and their religious and cultural needs. A service user confirmed that the home always provide their food of choice in relation to cultural needs, and a service user questionnaire stated that they always like the meals at the home. 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. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The daily record was comprehensive however; care should be taken to ensure that the outcome of the care given in relation to the health care needs is recorded. In relation to medication, one of the audits was incorrect, and the operations manager has arranged for daily medicine audits to be carried out. The service user’s social record should be completed daily, and also when they take part in an activity. The information about the service users enjoyment of the activity should also be recorded. The service users who were spoken with said that some activities took place, and included hand massage, card games and dominos. One service user also said that ministers visit the home regularly. One of the service user questionnaires stated that there are activities arranged by the home that you can take part in, and two questionnaires said that, “Sometimes there are activities that you can take part in.” One of the relative questionnaires stated, “Not enough stimulation is given.” A minimum ration of 50 of care staff should have an NVQ 2 or equivalent. Staff files should contain their induction records, and all care staff should have formal supervision at least 6 times a year. The results of any service user surveys should be published and made available to all interested parties. Please contact the provider for advice of actions taken in response to this Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. 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. One of the service users who were spoken with confirmed that they had visited the home before moving in. Service users are admitted following a full assessment of their needs, and to which the service user, his/ her representative (if any) and relevant professionals have been party. Each service user then has a plan of care based on the pre admission assessment. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 10 Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 The service users’ health, personal, and cultural needs are set out in a plan of care, and they receive the level of support they require to ensure that those needs are maintained. Service users are protected by the home’s policies and procedures for dealing with medicines. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Care plans were of a good standard and set out in detail the action that needs to be taken by care staff, to ensure that the health, personal and cultural needs of the service users are met. The daily record was also comprehensive however; care should be taken to ensure that the outcome of the care given in relation to the health care needs is recorded. One of the service user questionnaires said that they usually receive the care and support they need. The remaining questionnaires said that they always receive the care and support they need, and this was also reflected in what the Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 12 service users said when spoken with. One service user said that she was very happy living at the home, and that staff were kind. One of the relative’s questionnaires stated, “Overall the care is good from most carers.” The two questionnaires returned from the doctors stated that staff demonstrate a clear understanding of the care needs of service users, and that they are satisfied with the overall care provided to service users within the home. In relation to medication, one of the audits carried out were incorrect, in relation to the amount of medication recorded on the drug chart and that what should have been left in the bottle. The operations manager promptly arranged for daily medicine audits to be carried out in addition to their routine auditing. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 12 - 15 Without the documentation relating to the service users social needs been kept up to date, there is no evidence to suggest that the lifestyles experienced in the home matches their expectations and preferences, and satisfies their social, religious, and recreational interests and needs. A variety of meals are offered that take into account the likes and dislikes of the service users and their religious and cultural needs. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The service users’ social records were filled in on an ad hoc basis, therefore there was no documented evidence as to how the service users individual social, and religious needs were been met, and where the record had been completed the information did not show whether the service user had enjoyed the activity. Information was displayed in different areas of the home relating to the forth-coming outings, and service users commented on how they were looking forward to the events. The service users who were spoken with said that some activities took place, and included hand massage, card games and dominos. One service user also said that ministers visit the home regularly. One of the service user questionnaires stated that there are activities arranged Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 14 by the home that you can take part in, and two questionnaires said that, “Sometimes there are activities that you can take part in.” One of the relative questionnaires stated, “Not enough stimulation is given.” The menus offered a variety of food, and individual service users food preferences; specialised diets and cultural needs had also been taken into consideration when planning the menus. One questionnaire from a service user stated that they always like the meals at the home, and two questionnaires stated that they usually like the meals at the home. A service users confirmed that the home always provide their food of choice in relation to cultural needs. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 16 & 18 Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon in a timely manner. Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There is a complaints procedure which specifies how complaints may be made, and with an assurance that they will be responded to within a maximum of 28 days. There is also a whistle blowing procedure, and staff are aware of the procedure. One service user questionnaires stated that they always know how to make a complaint, one said usually, and one said sometimes they know how to make a complaint, and that they would inform their relative. When speaking with service users, they were aware of whom to speak with should they have any concerns, or wish to make a complaint. Staff have received abuse awareness training, and further training dates have been arranged. Staff were also aware of the procedure to following if they suspected that an incident of abuse had occurred. Astley Grange Nursing Home DS0000001108.V290627.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home is in a good state of repair and decorative condition. 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. The premises were clean and systems are in place to control the spread of infection. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 17 One of the questionnaires received from service users said that the home is always clean, and two questionnaires said that the home is usually clean. One of the service users who were spoken with also said that the home was kept clean. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 The staffing levels and skill mix were sufficient to meet the number and needs of service users. By the end of December 2006, a minimum of 50 of care staff should have an NVQ level 2 or equivalent. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users in the home. Questionnaires received from two relatives stated that there were sufficient staff on duty, and one stated that there was insufficient staff on duty. A service user questionnaire also commented that there were always staff available when you need them, one said staff were usually available, and one said sometimes staff were available, and that she had to wait for a hoist when it was in use. The two doctors questionnaires stated that there is always a senior member of staff to confer with. Thirty eight percent of care staff have achieved an NVQ level 2, or equivalent, and further staff have agreed to start the training later this year. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 19 The home employs a multicultural staff team, and is an equal opportunities employer. Staff records held equal opportunities monitoring forms. In relation to recruitment, the files inspected contained satisfactory information, and the operations manager is ensuring that all new recruitments follow the correct procedures, however, where a recruitment agency had carried out the recruitment and the induction of staff, the information relating to the induction was not available for inspection. It is recommended that records relating to induction are held in the individual staff’s file. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 & 38 The operations manager is providing additional management support to the home until a manager is appointed, and staff are feeling valued. Without the outcome of surveys being published, service users and their relatives do not have the evidence to show that the home is run in their best interest. Service users’ financial interests are safeguarded. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The manager’s position is vacant and the company is currently recruiting to the post. The home has a deputy manager, and staff are also receiving support from the operations manager, Mrs P Moore. Staff did say that Mrs Moore was Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 21 very supportive and approachable, and they knew how to contact her should the need arise. In relation to quality assurance, Mrs Moore held a relatives meeting at the end of May, and minutes were written. Mrs Moore also plans to continue the meetings on a regular basis, to enable relatives to air their views, and also keep them up to date with any change at the home. The company also send out questionnaires to service users, unfortunately the results of the questionnaire are not published. The results of service users surveys should be published and made available to current and prospective service users, their representatives and other interested parties. Service users personal finances were inspected and found to be correct. Satisfactory records were been maintained in relation to fire drills and emergency lighting. Staff are now having fire lectures and drills, and are also receiving movement and handling training. Staff who were spoken with confirmed that they had had the relevant training. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 22 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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 23 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. 1. Standard OP36 Regulation 18 (2) Requirement “The registered person shall ensure that persons working at the care home are appropriately supervised.” You are requested to send to the Commission a list of dates, when staff will receive supervision. Timescale for action 03/07/06 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 OP7 OP9 OP12 Good Practice Recommendations Daily record should show the outcome of the care that has been identified in the care plan. 9.3 – A record is maintained of current medication for each service user. 12.3 - The activities that the service user is involved in on a daily basis should be recorded in their individual care files. This information was also recommended at the last inspection. 28.1 - A minimum ratio of 50 of care staff to achieved an NVQ level 2 or equivalent. DS0000001108.V290627.R01.S.doc Version 5.2 Page 24 4. OP28 Astley Grange Nursing Home 5. 6. 7. OP30 OP33 OP36 30.2 – Staff files should contain the induction records. 33.4 – The results of service user surveys should be published and made available to current and prospective users, their representatives and other interested parties. 36.2 - Care staff should receive formal supervision at least 6 times a year. Astley Grange Nursing Home DS0000001108.V290627.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Office 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 Nursing Home DS0000001108.V290627.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!