Inspection on 13/09/06 for Beverley Grange Nursing Home

This inspection was carried out on 13th September 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.

Other inspections for this house

Beverley Grange Nursing Home 26/10/07

Beverley Grange Nursing Home 06/12/05

Beverley Grange Nursing Home 03/08/05

Beverley Grange Nursing Home 17/03/05

Beverley Grange Nursing Home 01/07/04

Beverley Grange Nursing Home 27/06/02

Beverley Grange Nursing Home 27/06/02

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beverley Grange Nursing Home Lockwood Road Molescroft Beverley East Yorkshire HU17 9GQ Lead Inspector Mrs Rosalind Sanderson Unannounced Inspection 13th September 2006 09:30 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 Beverley Grange Nursing Home DS0000000929.V311863.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. Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beverley Grange Nursing Home Address Lockwood Road Molescroft Beverley East Yorkshire HU17 9GQ 01482 679955 01482 679770 beverleygrange@beverleygrange.karoo.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) Molescroft Nursing Home (Holdings) Limited Ms Joy Mechelle Puckering Care Home 64 Category(ies) of Dementia - over 65 years of age (64), Old age, registration, with number not falling within any other category (64), of places Terminally ill over 65 years of age (64) Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Registered for 2 day places for patients over 55 years of age. Nursing care for two service users under 65 years One bed for young and disabled To admit one named service user under 65 years of age. Date of last inspection Brief Description of the Service: Beverley Grange is a purpose built home situated on a new housing development in a residential area on the outskirts of Beverley. The home is set in its own grounds with plenty of space for residents to sit and enjoy the fresh air. It was opened in 1999 to care for people requiring long term and respite residential care or nursing care including those suffering from a terminal illness. The home can accommodate up to 64 people. The home has two floors with the ground floor having the reception area and office provision with lounge/hairdressing salon. The corridors run off each side of this area and residents bedrooms are located along the corridors, along with bathrooms and toilets. All bedrooms have en suite facilities. One of the corridors leads to the bar lounge and conservatory whilst the other corridor leads to the ground floor dining room, kitchen and staff room. The first floor has the same layout with storage areas. Prospective service users are provided with information about the home in the form of a statement of purpose that includes a copy or summary of the last inspection report. The inspection report is also available in the home at all times. All prospective service users and their relatives are invited to visit the home if possible prior to moving in. The range of fees charged at the time of this inspection, 13/9/2006, were from £480.00 to £520.00 with the nursing care determination added on to this to give the final charge. Additional charges are made for chiropody (£9), hairdresser (from £6) and newspapers and magazines (various charges). Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the registered person on a pre inspection questionnaire; Comment cards returned from 8 service users, 14 relatives, 4 GP’s and 3 care managers. A visit to the home carried out by two inspectors. A site visit was carried out by two inspectors and lasted for seven hours. Five service users, four relatives and five staff were spoken with. Records relating to service users, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity within the home. This enabled the inspector to gain an insight of what life is like at Beverley Grange for the people that live there. The Manager and the deputy manager were available to assist throughout the day. What the service does well: Service users enjoy living at Beverley Grange. They are provided with a comfortable, pleasant place in which to live. Care needs are fully assessed before people come to live here so that staff are aware of these and service users are confident that their needs will be met. The healthcare needs of service users are met promptly and well. One service user commented, I feel that I always get the support I need’. A relative said, ‘I am very happy with all the care that…..receives’. Another relative said, ‘The staff always attend to ……. promptly and makes sure that …… receives medicines for pain at the correct times’ Activities are well organised at the home and service users are able to choose whether they take part or not. Relatives are always made to feel welcome and can visit anytime. One commented, ‘They bring me a cup of tea as soon as they know that I’m here.’ Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 6 Service users are attended to by well trained staff who are very much valued by the organisation and by the service users. Service users are listened to and are protected by the policies and procedures of the home. The manager is well liked and approachable. 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. Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 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 Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 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. 6 is not applicable Quality in this outcome area is good. Service users may be assured their assessed needs will be met. This judgement has been made using available evidence including a site visit. EVIDENCE: The records that were looked at showed that a comprehensive pre admission assessment is completed either before admission or as soon as possible following admission. This ensures that all the care needs of service users are acknowledged and planned for. All staff are then made aware of these needs through the service user’s care plans. Visits to the home are encouraged and service users commented, ‘this home met all the requirements that I had’. Another commented, ‘ the brochure that I was given answered all my questions about the home’ Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 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): 7,8,9,10 Quality in this outcome area is good. Service users have their healthcare needs met. This judgement has been made using available evidence including a site visit. EVIDENCE: All service users have all of their health and social care needs planned for. These care plans are made available for all staff and they confirmed that they have access to them. One service user commented, I feel that I always get the support I need’. A relative said, ‘I am very happy with all the care that…..receives’. another relative said, ‘The staff always attend to him promptly and he receives his medicines for pain at the correct times’ Medications are dealt with correctly ensuring that all service users receive prescribed medication safely. Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 10 There was evidence that the care staff review the plans regularly. However some service users were unaware that the home held written information about them or that they could look at this. One relative said, ‘There does not seem to be a formal procedure for discussing health issues.’ However this relative did say that they felt able to contact the home regarding any concerns. Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 11 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): 12,13,14,15 Quality in this outcome area is good. Service users are able to choose how they spend their days and are provided with a well balanced diet. This judgement has been made using available evidence including a site visit. EVIDENCE: The home employs four activities officers who work seven days a week including five evenings. There is a varied programme of activities that service users enjoy. Comments received include, ‘I enjoyed the dance we had one afternoon’ ‘The trip out to Burnby Gardens was enjoyable’ ‘We watched the World Cup on a large screen TV which was excellent.’ Some service users said that although there were plenty of activities they sometimes chose not to join in, as they may not always enjoy what was offered. They confirmed that this was fine and the staff respect their decisions. Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 12 Visitors to the home are made to feel welcome. All of those surveyed confirmed this. One relative said, ‘They bring me a cup of tea as soon as they know that I’m here.’ Relatives said they are able to visit at anytime. Lunch was taken with the service users and staff were seen to help those service users needing help in a considerate way. The meals looked appetising and were well presented. One service user commented, ‘The lunch was delicious, it always is’. The menus provided were varied and provided a well balanced diet. However some comments received include ‘There does not seem to be much choice available’ and ‘I would welcome more variety’. Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. Service users are listened to and protected This judgement has been made using available evidence including a site visit. EVIDENCE: The complaints procedure is clear and accessible to service users, visitors and staff. All those spoken with confirmed they would feel happy to bring up any concerns with the manager. Relatives confirmed that they knew about the complaints procedure and those who had brought up concerns were generally satisfied with how they were handled. The adult protection policy is clear and all staff have received training in this area. All staff are issued with a quick reference guide issued by the local authority. A complaint had been referred to the local authority for investigation who had concluded that it had been handled correctly. Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 14 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): 19,22,26 Quality in this outcome area is adequate. Service users live in comfortable surroundings but some elements within the environment and the way some equipment is used may place them at risk. This judgement has been made using available evidence including a site visit. EVIDENCE: The home is decorated and maintained well. The gardens are on a level access and well used by service users with ample seating available. The new conservatory area is much appreciated and service users enjoyed a recent tea dance in this area. Private accommodation is clean and pleasantly decorated. Service users have been able to personalise their rooms with photos and ornaments from home. One said, ‘Although this isn’t home it’s the next best thing’ Some fire doors were held open with door wedges. A visit by the fire officer in April 2006 had highlighted this as a problem. It was pointed out to the Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 15 manager and she was given an official notice to deal with this. She made immediate arrangements for the door wedges to be removed. Equipment that had been identified as needed by service users was provided. This included special beds that assisted staff to care for service users and increased service users comfort. Some beds had been fitted with bed rails. However a full assessment had not been carried out and in some cases these were been used in an unsafe way. An example of this is that they were used without protection around the rails to prevent entrapment and injury. Wheelchairs were being used without footplates in place. Again the manager was given an official notice and she arranged for an immediate re assessment of their use and made arrangements for them to be used safely. Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 16 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): 27,28,29,30 Quality in this outcome area is good. Service users are cared for by well trained and safe staff. This judgement has been made using available evidence including a site visit. EVIDENCE: Staff are now recruited safely and all the necessary checks are in place before they are deployed. Evidence of induction training and mandatory training was seen. Staff receive regular supervision. The home employs a full time training officer and she provides excellent training in all areas for all staff. External training is also arranged where appropriate. This ensures that well-trained, motivated staff that are valued by the organisation always attend service users. Currently 47 of care staff have achieved a qualification in care at NVQ level 2 or above. Several members of staff are awaiting final verification of their portfolios. Once this is complete the home will have achieved above the 50 target for care staff holding an NVQ qualification. The home encourages and enables the nursing staff to maintain their professional skills and qualifications. Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 17 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): 31,33,35,38 Quality in this outcome area is good. The home is well managed but a more proactive approach would address health and safety issues promptly. This judgement has been made using available evidence including a site visit. EVIDENCE: The manager is a trained nurse with many years experience in care. She holds the registered Managers Award. She has a very ‘hands on’ approach to care and works in her nursing capacity two days per week. The other days she has supernumerary hours to fulfil her management responsibilities. Staff and relatives spoken with feel the manager has an open, inclusive approach and operates an open door policy. Relatives, staff and a service user were observed freely approaching her during the day. The home has a happy atmosphere. Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 18 The providers and the manager always respond promptly to any requirements made and have done so following this inspection. The administrator deals with some personal allowances for service users. Accurate records are kept of all transactions made. Staff spoken to confirmed that they feel well supported by the manager to help them achieve good outcomes for service users. They have regular supervision when training needs and progress are discussed. Quality assurance within the service is carried out. The findings are used to inform the annual development plan To ensure the continued safety and good care of service users the issues identified around health and safety need to be addressed and managed pro actively. Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 19 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X 1 X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 20 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. 2. Standard OP19 OP22 Regulation 23(4) 13(4(c)) Requirement Fire doors must not be held open by unauthorised means Risk assessments must be carried out for the use of equipment in the home. Control measures must be put in place for identified risks. This is in specific relation to: • The use of bedrails • The use of wheelchairs Timescale for action 13/09/06 13/09/06 Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 21 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 It is recommended that the care plans are signed by the service user and/or their representative to show they are involved with the planning of care. It is recommended that the quality assurance system is further developed to gain stakeholders views on the service provided in particular in relation to: • Meals provided. • Activities provided. 2. OP33 Beverley Grange Nursing Home DS0000000929.V311863.R01.S.doc Version 5.2 Page 22 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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