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Inspection on 08/11/05 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 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Service users needs are met by the numbers and skill mix of staff.

What has improved since the last inspection?

In relation to infection control, paper towels have been provided in the laundry room. The emergency lighting is tested monthly as recommended.

What the care home could do better:

All service users must have a written care plan stating how their needs in respect of their health and welfare are to be met. The plans must also be reviewed. The daily activities that the service user is involved in should be recorded in their individual file together with their interests and hobbies. All staff must have adult protection awareness training, movement & handling training and fire lectures. In relation to recruitment, the owner must ensure that the required employment checks are obtained prior to staff working at the home. Failure to comply with these requirement may lead to further action being taken by the Commission. The inspector would like to thank Mrs Gardener, Mrs Dixon, the staff and service users for their hospitality and time throughout the inspection.

CARE HOMES FOR OLDER PEOPLE Astley Grange Nursing Home Woodhouse Hall Road Woodhouse Hill Fartown Huddersfield West Yorkshire HD2 1DJ Lead Inspector Karen Summers Announced Inspection 8th November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 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.V264206.R02.S.doc Version 5.0 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@highfield-care.com 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.V264206.R02.S.doc Version 5.0 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 12th July 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 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 Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an announced inspection on the 8th November 2005, commencing at 9.20am and the duration of the inspection was 6.25 hours. Mrs Claire Dixon, the proposed manager, and Mrs Jacky Gardener, Regional manager, were present at the inspection. The following inspection methods have been used in the production of this report; sampling of records, care plans, individual discussion with 7 service users, discussion with management and staff and document reading. What the service does well: 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. Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 6 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.V264206.R02.S.doc Version 5.0 Page 7 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): EVIDENCE: These standards were not inspected on this occasion. Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 8 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 Service users could potentially be at risk when their needs in relation to health, personal and social care have not been identified in an individual plan of care. EVIDENCE: New care documentation is in the process of being introduced, and staff are receiving training on how to complete the documentation. The records varied between author, and a number of the records were comprehensive and a good standard, whilst others lacked important information (i.e. care plans,) and had not always been reviewed monthly as the standards recommend. All nurses have a duty of care when caring for service users, and therefore advised to refer to the Nursing & Midwifery Council Guidelines for records & record keeping. All service users must have a written care plan stating how their needs in respect of their health and welfare are to be met. The plan must also be kept under review. Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 9 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 Without the interests/activities of the service users been recorded, there is no evidence to suggest that the lifestyles experienced in the home match their expectations and preferences, and satisfies their social, and recreational interests and needs. 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 the service user is involved in on a daily basis should also be recorded in their individual files together with their interests and hobbies. Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 10 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 can be confident that their complaints will be listened to, taken seriously and acted upon in a timely manner. Until all staff have received Adult Protection Awareness training, service users are not protected from the potential risk of abuse. 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 a whistle blowing procedure. According to the training records not all staff has had adult protection awareness training. All staff must have the training. Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 11 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): EVIDENCE: These standards were not inspected on this occasion. Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 12 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 - 29 The staffing levels and skill mix were sufficient to meet the number and needs of service users. By the end of December 2005, a minimum of 50 of care staff should have an NVQ level 2 or equivalent. Until the appropriate documentation is obtained for all staff prior to them working at the home, service users are potentially not protected by the home’s recruitment practices. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users in the home. Four percent of care staff have achieved an NVQ level 2, or equivalent, and a further twenty-two 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. In relation to recruitment, one of the staff files did not contain two written references, and another file did not contain a photograph of the member of staff. The owner must ensure that two written references and a photograph are obtained for all persons employed at the home. Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 13 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): 35 & 38 Service users personal finances were inspected and found to be correct. Unless the required fire alarm checks are carried out, the health and safety of service users and staff could be potentially at risk. EVIDENCE: Service users personal finances were inspected and found to be correct. The company is in the process of changing how the records are maintained. Care should be taken to ensure that personal allowances of service users are not pooled. Routine health & safety checks are carried out and satisfactory records are kept. Fire alarms are tested weekly, and emergency lighting is tested monthly. According to staff training records not all staff have had annual movement and handling training, or had two fire lectures a year. All staff are requested to have annual movement and handling training, and should also have two fire lectures a year. Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 14 Ten service users comment cards and seven relatives/ visitors comment cards were received by the commission. Six service users said that the home provides suitable activities; one said sometimes the activities were suitable and three service users said that the activities were not suitable. Two service users said that their privacy was not respected, four said that it was, one said sometimes and one service user was not sure. Out of the seven-relatives/ visitors cards four people were satisfied with the overall care provided, one person had reservations, and two people were not satisfied with the overall care provided. The concerns of the service users and relatives/ visitors were discussed with the manager and regional manager. Southern Cross Operations Limited have recently become the owners of the home, and the manager Mrs Dixon and Regional manager, Mrs Gardener, have also recently joined the home. Mrs Gardener said that the company is committed to the welfare of the service users, and there are plans to provide intense training for all the staff, which will hopefully address the concerns that were expressed. Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 1 X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X X 1 Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? NO Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 17 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 OP7 &OP8 Regulation 15-(1) & (2)(b) Requirement 15.-(1)“Unless it is impracticable to carry out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan (“the service user’s plan) as to how the service user’s needs in respect of his health and welfare are to be met.” (2)”The registered person shall(b) keep the service user’s plan under review.” The registered person shall make arrangement, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. You are requested to confirm in writing by 11/12/05 when abuse awareness training can be arranged for all staff. The registered person must obtain the information & documents as specified in the regulations & schedule, which includes: • Proof of the person’s identity, including a recent photograph. • Two written references relating to the person. The registered person shall make suitable arrangements to provide a safe system fro moving and handling service users. • All care staff must have annual movement and handling training. You are requested to confirm in writing by 11/12/05 when the training will be carried out. The registered person shall after consultation with the fire authority – Make arrangements for persons working at the care home to receive suitable training in fire prevention. You are requested to confirm in writing by 11/12/05 when the training will be carried out. DS0000001108.V264206.R02.S.doc Timescale for action 06/01/06 2. OP18 13.-(6) 11/12/05 3. OP29 19-(4)(b) Schedule2 19/01/06 4. OP38 13.-(5)(a) 11/12/05 5. OP38 23.(4)(d) 11/12/05 Astley Grange Nursing Home Version 5.0 Page 18 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 OP7 Good Practice Recommendations The nurses should refer to the Nursing & Midwifery Council Guidelines for records & record keeping. (All nurses have a duty of care when caring for service user.) • 7.4 – The service user’s plan should be reviewed at least once a month. • 12.3 The activities that the service user is involved in on a daily basis should be recorded in their individual care files together with their interests and hobbies. • 12.4 Up to date information about activities should be circulated to all service users in formats suited to their capabilities. A minimum ratio of 50 trained members of care staff to achieved an NVQ level 2 or equivalent, by 31st December, 2005. Where the money of individual service users is handled, the manager should ensure that the personal allowances of those service users are not pooled. All staff should have bi annual fire lectures and drills. • 2. OP12 3. 4. 5. OP28 OP35 OP38 Astley Grange Nursing Home DS0000001108.V264206.R02.S.doc Version 5.0 Page 19 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. 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