This inspection was carried out on 15th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
CARE HOMES FOR OLDER PEOPLE
Bedale Grange Nursing Home 28 Firby Road Bedale North Yorkshire DL8 1AS Lead Inspector
John McGarva Unannounced Inspection 15th December 2005 10:30 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 Bedale Grange Nursing Home DS0000064737.V270489.R01.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. Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bedale Grange Nursing Home Address 28 Firby Road Bedale North Yorkshire DL8 1AS 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) 01677 422980 01677 422980 Bedale Grange (TFP) Ltd Mrs Julie Atkins Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th September 2005 Brief Description of the Service: Bedale Grange is a care home registered to provide Nursing and Social care for up to 21 residents. It is located just west of the small market town of Bedale and was first registered as a Nursing home in September 1985. The home is a large detached pebble-dashed building with three floors including ground and single storey extensions have been added. There is an electric chair lift from the ground to the first floor and the residents are accommodated on the ground and first floors only. The front elevation facing south overlooks a large garden area that has a pergola with lawn, mature trees and shrubbery extending beyond. Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection that took place on Thursday 15th December 2005 and the manager Mrs Julie Atkins was available to assist throughout the process. The focus of the inspection was to follow up on matters raised at the last inspection on the 13th September and talk to the resident’s and staff. The building was previously a private Victorian residence and in consequence there are environmental constraints, which make providing care a challenge for the staff. With 21 residents when full it is one of the few small care homes providing nursing care in North Yorkshire and on the day of inspection there were 17 residents. Ownership of the home changed on July 2005 and there has been a significant programme of decoration and refurbishment, which continues. What the service does well: What has improved since the last inspection?
Further improvements are continuing including the provision of a shower room and rearranging the bathroom on the ground floor. The first floor bathroom is being refurbished and the toilet moved to provide easier access.
Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 Page 6 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. Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 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 the following standard(s): 3 and 4. The nursing and care staff have the required training and skills to meet identified needs. EVIDENCE: The nursing record documentation is being changed to include more details of the histories and health indicators of the residents. The nursing and care staff continues to be well motivated in providing good quality care. Residents made positive comments about the care they receive. Intermediate care is not provided in this home. (Standard 6.) Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 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 the following standard(s): This standard was not inspected on this occasion. EVIDENCE: Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 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 the following standard(s): This standard was not inspected on this occasion. EVIDENCE: Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 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 the following standard(s): This standard was not inspected on this occasion. EVIDENCE: Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 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 the following standard(s): 19 21,22,24,25 and 26. The provider has made improvements to the general environment and further work is planned. EVIDENCE: The home meets the standards for pre-existing homes registered before 2002. There are eleven single and five shared rooms, representing 48 of the residents sharing a room when full and there are no rooms with en-suite toilet facilities. There is a chair lift providing access to the first floor rooms. New flooring has been laid at the entrance and in the manager’s office. A new shower room is now being created in one of the two ground floor bathrooms and this will be of great benefit to both staff and residents alike. A liquid soap dispenser has been provided in the downstairs sluice room.
Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 Page 13 Future works for the home include: • The provision of an island bath in the ground floor from where the care staff can access the resident from both sides. The lighting in this room needs to be replaced, preferably by a suitable sealed diffuser type strip lighting unit. Grab rails are provided in the bathrooms but not in the corridors although some of the corridors are too narrow to accommodate grab rails. Lockable space for the resident to store money, valuables or medication is only available in five of the newly refurnished rooms. Thermostatically controlled valves to ensure the water does not exceed 43 degrees centigrade are soon to be installed in six rooms which do not have them. A suitable qualified person including an occupational therapist has not yet assessed the premises. Grab rails are provided in the bathrooms but not in the corridors although some of the corridors are too narrow to accommodate grab rails. • • • • • Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 Page 14 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): 29 and 30. The residents receive a good standard of nursing care from well-motivated staff that is supported in what they do. The staff personal files include all the required information. EVIDENCE: Suitable recruitment policies and procedures are in place and all relevant documentation including passport and record that CRB checks have been undertaken. All staff receives induction training at the start of their employment and further training is provided at sequenced intervals in accordance with good practice. All care staff now has an individual training plan. The in house trainer employed by the provider for the four homes in the group took place recently. Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 Page 15 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. A quality assurance system needs to be introduced. EVIDENCE: There is as yet no quality assurance system in place and this is a matter that the manager will consider with the new provider in the future. Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 Page 16 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 4 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x 1 2 x 1 1 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 1 x x x x x Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? YES 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. 2. 3. 4. Standard OP21 OP24 OP25 OP33 Regulation 21.2 (n) 23(2)(m) 13(4)(c) 24(1)(a)( b) Requirement Timescale for action 01/04/06 All bathrooms must be brought into usable condition. Lockable storage space must be 01/04/06 provided in each of the resident’s rooms. Hot water outlets in each of the 01/04/06 resident’s rooms must not exceed 43 degrees centigrade. A quality assurance system must 01/04/06 be introduced. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 3. Refer to Standard OP22 Good Practice Recommendations Suitably qualified persons including an occupational therapist should assess the premises. Grab rails should be provided in corridors, toilets and communal rooms. Bedale Grange Nursing Home DS0000064737.V270489.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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