Inspection on 26/10/07 for Beverley Grange Nursing Home

This inspection was carried out on 26th October 2007.

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 13/09/06

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 Eileen Engelmann Key Unannounced Inspection 26th October 2007 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.V353727.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.V353727.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 75 Category(ies) of Dementia - over 65 years of age (64), Old age, registration, with number not falling within any other category (75), of places Terminally ill over 65 years of age (64) Beverley Grange Nursing Home DS0000000929.V353727.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 13th September 2006 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 people to sit and enjoy the fresh air. The home was opened in 1999 to provide long term and respite stays, looking after older people who need residential care or nursing care. The home is registered for 64 older people, some of whom may have dementia, and the service also includes a number of Bungalows in the grounds for more able-bodied people who need minimal care. The Bungalows provide up to a total of 11 additional places for older people. The home has two floors with the ground floor having the reception area and office provision with a lounge and a hairdressing salon. The corridors run off each side of this area and peoples bedrooms are located in these areas, along with bathrooms and toilets. One of the corridors leads to the bar-lounge, 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. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home, and copies are on display in the entrance hall of the home. The latest inspection report for the home is available from the manager on request. Information given by the manager during this visit indicates the home charges weekly fees from £520.00 to £540.00 plus the nursing band fee (where applicable). People will pay additional costs for optional extras such as hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these is available from the manager. Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 5 Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Information has been gathered from a number of different sources since the last visit to the home in September 2006, this has been analysed and used with information from this visit to reach the outcomes of this report. The unannounced visit was carried out with the manager, staff and people living at Beverley Grange. The visit took place over 1 day and included a tour of the premises, examination of staff and people’s files and records relating to the service. Informal chats with a number of people and staff took place during this visit; their comments have been included in this report. Questionnaires were sent out to a selection of relatives, people using the service and staff and their written response to these was good. We received 11 back from relatives (65 ), 14 from staff (56 ) and 10 from people using the service (55 ). The manager completed an Annual Quality Assurance Assessment and returned this to the Commission within the given timescale. The local funding authority (East Riding Council) has received one complaint from a relative about care of a person living in the home. However, the individual making the complaint decided not to proceed with their issues and their concerns were noted by the authority and passed on to the Commission for Social Care Inspection. These were looked at as part of this inspection and no further action from the home is required. Two safeguarding of adults referrals (abuse) have been made to the local authority since the last inspection. Both were allegations of poor staff practice. The local authority and the manager have investigated one; a member of staff was subsequently disciplined by the home and has left the service, the other is still under investigation. What the service does well: All of the people spoken to are positive about the home and like living there. People living in the home and relatives expressed their satisfaction during this visit regarding the care given, service received and the living environment of the home. Staff are hard working and do their best to meet the needs of those people living in the home. Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 7 People being cared for have good access to professional medical staff and are able to access external services such as dentists, opticians, physiotherapists, chiropody and dieticians, so their health is looked after and they are kept well. People living in the home said they are offered a good choice of meals and they enjoyed the quality of food. Specific wishes are catered for and they have plenty to eat and drink throughout the day. Relatives of the people living in the home said that they are made to feel welcome by the people working in the home and that they can visit when they please. The home has an enthusiastic team of people working within the service, who like doing their jobs and learning more about how to do it well. The people working in the home want to make sure that the people who live in the home receive good care. 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. The summary of this inspection report can be made available in other formats on request. Beverley Grange Nursing Home DS0000000929.V353727.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 Beverley Grange Nursing Home DS0000000929.V353727.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People undergo a full needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met by the service. EVIDENCE: Each person has their own individual file and four of those looked at had a need assessment completed by the funding authority or the home before a placement is offered to the person. The home develops a care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from the person and their family. Those people at the home who receive nursing care have undergone an assessment by a NHS registered nurse from the local Primary Care Trust, to determine the level of nursing input required by each individual. The majority of people and relatives said they received sufficient information to make an informed choice about the service before accepting the placement offer. Two people spoken to told us that their families came to look around for Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 10 them and were confident that the home would meet their needs. Both individuals received written information about the home and felt they had been consulted about the move. Staff members on duty were knowledgeable about the needs of each person they looked after and had a good understanding of their specific problems/abilities and the care given on a daily basis. Discussion with people showed that they were satisfied with the care they receive and have a good relationship with the staff. Two relatives commented that ‘occasionally care is not as good as it could be, but staff attend promptly when asked’ and ‘the quality of care is variable, and very dependant on certain individuals’. However, the people using the service who spoke to us were satisfied with the staff and enthused about the way they were able to make choices and decisions in their everyday lives. One person said ‘it is like my own home, the staff are wonderful and I am looked after well’ another said ‘the staff are hands on and very caring’. Information from the Annual Quality Assurance Assessment and discussion with the people living in the home indicates that all of the people are of white/British nationality, although there are a number of people with different faiths and religions. The home does accept people with specific cultural or diverse needs and everyone is assessed on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. The home employs a training officer whose role is to ensure that all staff go through an induction before starting work and that an appropriate training programme is in place to ensure the needs of people using the service are met. Information from the training files and training matrix indicates that the majority of staff are up to date with their basic mandatory safe working practice training, and have access to a range of more specialised subjects that link to the needs of people using the service. The employment records show that the manager is using a selective approach to recruitment; ensuring new staff have the right skills and attitude to meet the needs of people in the home. Checks of the staffing rotas and observation of the service showed that the home employs male and female care staff and a number of staff are from different countries and cultures. Discussion with the people living in the home indicates that they have no difficulties communicating with the staff and that they can express their preferences of staff gender for individuals giving their personal care. The home does not have any intermediate care beds and therefore standard six does not apply to this service. Beverley Grange Nursing Home DS0000000929.V353727.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, personal and social care needs of people using the service are being met by the service and staff. Improvements to the staff performance around recording within the care plans and medication system must be made, to ensure the peoples’ health and welfare are protected. EVIDENCE: A recommendation from the last report in September 2006 said ‘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’. During this visit it was seen that two out of the four care plans looked at had been signed by the person or their family. This recommendation is partly met and will remain on this report. Information from the surveys indicates that the majority of people who responded are satisfied that the staff give appropriate support and care to Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 12 those living in the home. People said they are able to make their own decisions about their daily lives most of the time; that staff treat them well and listen and act on what they say. Comments from the surveys said ‘excellent standard of care, and staff offer help quickly. Staff give support and help where needed’, and ‘the staff keep me informed, listen and act upon my comments, all the staff are caring and sensitive to the needs of the people using the service’. The care of four people was looked at in depth during this visit and included checking of their personal care plans. The four examined set out the health, personal and social care needs identified for each person. The plans looked at have been evaluated on a monthly basis and any changes to the care being given is documented and implemented by the staff. Risk assessments were seen to cover pressure sores, nutrition, moving/handling and activities of daily living. There was one area in the care plans that needed to improve and this was: • The trained nurses are not always recording in the daily diary notes and this is not acceptable practice. The manager told us that she is aware of the above issues and has called a staff meeting to discuss them with the relevant people. The manager said that she will audit the care plans weekly and discusses the role and responsibilities of the trained nurses through the supervision process. Relatives are satisfied that the home keeps them up to date with any changes in their loved one’s care. Individuals said ‘the care home does an exceptional job caring for my relative in all ways. All the staff have good personalities and are very positive and caring’, and ‘they meet the needs of my relative who requires 24 hour care’. People said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Comments from the people and relatives indicate they are satisfied with the level of medical support given to the people living at the home. The staff weighs everyone on a regular basis and evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. The nurses within the home carry out specialist tasks such as PEG tubes/feeding regimes and wound dressings. Pressure areas are monitored carefully and proactive measures include risk assessments and special mattresses/beds and seat cushions. People are able to access physiotherapy through their GP and the home also has input from its own physiotherapist. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. Two people, who spoke to us, administer their own medication and have been Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 13 provided with lockable space to store their medicines in. They understand how the system of ordering medication works within the home and told us that the staff checked with them to make sure they are okay and have no problems. Checks of the medication records showed that overall these are well maintained and kept up to date, however there were a few areas that need addressing; • There are a number of missing signatures where staff have given out medication, but have not signed on the record sheet. Discussion with the manager indicated she is aware of the problem and has called a meeting to talk about this unacceptable practise. • Where staff are hand writing medication onto the sheets (transcribing), they are not following best practice. Staff should include the amounts of medication received or brought forward, and have two staff sign the entry to indicate they have both witnessed that the information on the sheet is correct (this is a good practise measure). • It was noted that medication already held in the home when a new medication sheet is started is not added to the supplies on the medication record sheets. This should be done so as to ensure a running total is available at all times and an audit of stock is easy to carry out (this is a good practise measure). Checks of the controlled drugs and register showed that these are up to date, accurate and well managed. People and relative comments show they are very satisfied with the care and support offered by the staff. Chats with people using the service revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. People said ‘ our relative is always clean and tidy, staff chat to him/her and know her name, this includes all the staff not just the carers’. ‘Staff have the welfare of the people as a priority, they show great understanding and affection for those they care for’. Observation of the service showed there is good interaction between the staff and people, with friendly and supportive care practices being used to assist people in their daily lives. Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are provided with choice and diversity in the activities and meals provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. EVIDENCE: The home employs four part-time activity organisers who together produce a weekly programme of events that spans daytimes and evenings including weekends. People living in the home have a copy of the activity programme in their bedroom. They can discuss the events taking place, and decide what they would like to do in the future, during the relative and resident meetings, which are held regularly. Individuals from the bungalows are invited to attend anything going on in the home and there is a real community spirit within the service. Activity records are in place showing which events people have taken part in; one person told us that ‘there is a very instructive art teacher who is always constructive in her comments’. Those people who spoke to us said they were satisfied with the level of activities within the home and enjoyed taking part in the social events. Every two weeks an entertainer comes into the Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 15 home, and trips out are organised during the summer months using local transport companies. Information from peoples’ files indicates that there are a number of individuals who follow different spiritual faiths, including Mormon, Catholic, Church of Scotland and Church of England. People were attending the weekly church service during this visit, this is held in one of the small lounges. Those of different faiths are able to celebrate their religious festivals, with staff encouraging them to continue following their religious observances and beliefs. The home provides special meals and cakes for birthdays and helps people celebrate all major Christian festivals such as Easter, Harvest Festival and Christmas. Relatives and visitors are on the whole very positive about the home and its service. Individuals told us that ‘care of the people living in the home is very good. Staff sit and chat with people and put on music and the television when relatives are not able to visit’. One person said ‘It is a home from home, I spend a lot of time with my relative and staff always make me welcome and let me help with my relatives care’. Another person commented that ‘the staff are supportive and understanding, we are made welcome at any time’. People spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. Staff have received training around current legislation in equality, diversity and disability matters in their induction and National Vocational Qualification’s, so they understand individual rights within the care home and out in the community. People told us that the home encourages them to bring in small items of furniture and personal possessions to decorate their bedrooms. There are meetings where the viewpoints and opinions of those living in the home can be expressed and the management team will listen and take action were needed. Visitors said they are kept informed of any important issues affecting their friend/relative and felt that staff did a good job of supporting people to live the lives they choose. There is a wide range of leaflets in the entrance hall of the home, these offer people information and advice on different matters including, advocacy, finance, wills and individual’s rights. Comments from the people living in the home and their relatives are on the whole very positive about the meals and kitchen service provided. Individuals commented that ‘the food is very good’, and ‘the meals are superb’. The lunchtime meal was well presented and offered a good choice of food, menus were available and the dining rooms were welcoming and spacious. Staff were organised when serving the meal and a number of individuals were seen to offer assistance to people who needed help with eating and drinking. Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a satisfactory complaints system with some evidence that peoples’ views are listened to and acted upon. EVIDENCE: Checks of the records in the home showed that there have been five formal complaints made to the service since the last inspection. These involved issues around staff attitudes and the care provision. The manager has investigated each problem and taken appropriate action to resolve the matters. Her written responses to the complainants are kept on file. The local funding authority (East Riding Council) has received one complaint from a relative about care of a person living in the home. However, the individual making the complaint decided not to proceed with their issues and their concerns were noted by the authority and passed on to the Commission for Social Care Inspection. These were looked at as part of this inspection and no further action from the home is required. People’s survey responses showed individuals have a clear understanding about how to make their views and opinions heard and those people spoken to said ‘the manager comes round every day to see us and will discuss any problems at this time’. Relatives are aware of the complaints procedure and are confident of using it if needed. Those who responded to the surveys said that the manager was efficient and effective in answering queries and they were satisfied with her Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 17 actions. One person said ‘on the few occasions that I have raised a query this has been met with understanding, agreement and action’. Two safeguarding of adults referrals (abuse) have been made to the local authority since the last inspection. Both were allegations of poor staff practice. The local authority and the manager have investigated one; a member of staff was subsequently disciplined by the home and has left the service, the other is still under investigation. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of resident’s money and financial affairs. The staff on duty displayed a good understanding of the safeguarding of adults procedure. They are confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. The majority of staff have received training in Safeguarding of Adults, management of challenging behaviour and dementia care. Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of environment within the home is good, providing people with a comfortable and homely place to live. EVIDENCE: In the last report (September 2006) a requirement was made that said ‘Fire doors must not be held open by unauthorised means’. At this visit it was seen that bedroom doors have been fitted with electronic door openings, which close on activation of the fire alarm. So this requirement is met. The manager has a record of the ongoing maintenance and renewal programme and this indicates that the provider is committed to improving the facilities and environment within the home. At the time of this visit the main lounge carpet (ground floor) was being replaced and new chairs are on order for the central lounge and corridors (first Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 19 floor). Plans are in place to refurbish and decorate the Bar lounge within the next six months. Areas that should be considered for further refurbishment include • The downstairs corridor carpets, which are marked and worn, • The pink lounge upstairs, where some people have told us they do not like to sit as the décor is too bright and not appealing. • Various bath panels that are broken due to knocks from equipment and people during the bathing routines. People have access to outside space, where there are lawned and garden areas, paved patio sections, a green house where people can potter at will, and a good selection of chairs and tables to sit at and enjoy the sunshine in the better weather. All walkways inside and out are flat to aid mobility in those who use wheelchairs or walking aids. Inspection of the home showed that it has been designed and built to meet the needs of disabled individuals. Doorways to bedrooms, communal space and toilet/bathing facilities are wide enough for wheelchairs, and corridors are spacious and have enough room for people in wheelchairs or with walking frames to pass by comfortably. The people living in the home have access to seven bathrooms and two walk in shower rooms that are spacious and well thought out. The home is built on two floors with flat walkways inside and out, providing safe and secure footing for people with limited mobility. Access to the upper floor is by use of staircases or the passenger lift. Discussion with the staff and manager indicates that there is a wide range of equipment provided to help with the moving and handling of people using the service and to encourage their independence within the home. This includes mobile hoists, bath hoists, stand aids and handrails. There are eleven specialist nursing beds provided in the home to aid staff in caring for people and make life more comfortable for individuals who spend a lot of time in bed. The company physiotherapist visits the home twice a week to give advice, support and assistance to the staff and people living in the home. In the last report (September 2006) a requirement was made that said ‘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’. Wheelchairs in use were being moved correctly with people’s feet on the footplates to prevent injuries to their legs. Bed rails seen in use were fitted with bumper covers to prevent entrapment and basic risk assessments were in people’s care plans. The manager could make the bedrail risk assessments more robust by including better information about what the perceived risks are to warrant bed rails to be in place and that covers are to be fitted. Also, where people would be a greater risk if bedrails were put in place, what alternative measures are Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 20 being taken to prevent people falling from their beds and sustaining injury. These risk assessments should be signed by the individual or their representative to show they have consented to this form of restraint. This requirement has been partly met and will remain as a recommendation on this report. All areas within the home are warm, safe and comfortable. The domestic staff do an excellent job of keeping the premises clean and odour free. Comments from the day of this visit indicate that the people using the service find the home to be spotlessly clean and they are satisfied with the laundry service provided by the home. Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standards of recruitment, induction and training of staff are good with appropriate employment checks being carried out and staff demonstrating a clear understanding of their roles, ensuring that people are protected from risk and looked after by motivated and knowledgeable people. EVIDENCE: Comments from the people using the service, relatives and staff are on the whole very positive about the staffing levels within the home, and individuals feel that there is a good standard of care being given to the people living in the home. There are three vacancies in the home for care hours, at present the core staff group are covering the shifts and some agency is being used. Adverts are in the papers for the vacant positions and interviews are booked for next week. Information from annual quality assurance assessment about the number of staffing hours provided, and information gathered during the visit about the dependency levels of the residents, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the minimum hours asked for in the recommended guidelines. The home has its own training officer and she ensures that all new staff receive an induction. 68 of the care staff have achieved an NVQ 2 or 3. Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 22 The home provides a mandatory staff-training programme and this includes some more specialised training to help staff develop their skills and knowledge around customer care, infection control, dementia, palliative care, racial harassment and guardianship. Each member of staff has had one to one time with the training officer to discuss their training needs and future objectives and development. Training plans are in place for all staff and a training matrix shows the overall needs of the team. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of four staff files showed that police (CRB) checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Nurses at the home undergo regular registration audits with the Nursing and Midwifery Council to ensure they are able to practice. Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is satisfactory overall and the home reviews aspects of its performance through a programme of audits and consultations, which includes seeking the views of people using the service, staff and relatives. EVIDENCE: The manager is registered with the Commission for Social Care Inspection and has completed her Registered Manager’s Award. She attends regular training updates to keep her skills and knowledge current and proactive. The manager has been in post for nearly 6 years and is supported by a deputy and senior nurses. Discussion with the manager indicates she operates an open door policy for people, staff and visitors to come and talk to her. Regular supervisions and staff meetings take place to ensure there is open communication between all people working in the home. Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 24 The home has achieved the local councils quality award (QDS) parts one and two and Investors in People status. Meetings for people using the service are held on a regular basis and minutes are circulated to people living in the home. Staff have meetings with the manager and everyone is encouraged to join in with discussions and voice their opinions. People and staff agreed that they are able to express ideas; criticisms and concerns without prejudice and the management team will take action where necessary to bring about positive change. Policies and procedures within the home have been reviewed and updated to meet current legislation and good practice advice from the Department of Health, local/health authorities and specialist/professional organisations. The manager completes in-house audits of the home and its service on a monthly basis, and the responsible individual does spot checks and completes the regulation 26 visits. A copy of the monthly visit is available within the home for inspection. Feedback is sought from the people using the service and relatives through regular meetings and satisfaction questionnaires, and the manager is in the process of producing an annual development report as part of this process to highlight where the service is going and/or indicate how the management team is addressing any shortfalls in the service. The importance of the Commission’s document called Key Lines Of Regulatory Assessment (KLORA) was discussed with the manager, and how it is used in the inspection and report writing process. The home’s administrator was on leave at the time of this visit and we were unable to look at people’s personal allowances and the records kept around this. Standard 35 will be looked at in full during the next visit to the service. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff have received training in safe working practices or are due to attend later in the year, and the manager has completed generic risk assessments for a safe environment within the home. Risk assessments were seen regarding fire, moving and handling, bed rails and daily activities of living. Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 25 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 3 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 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 person and/or their representative to show they are involved with the planning of care. The manager should audit the care plans weekly and discuss the role and responsibilities of the trained nurses through the supervision process. The manager should ensure that the trained nurses are signing the medication sheets on a daily basis. The manager should make sure that where staff are hand writing medication onto the sheets (transcribing), they include the amounts of medication received or brought forward, and have two staff sign the entry to indicate they have both witnessed that the information on the sheet is correct. Staff should ensure that medication already held in the home when a new medication sheet is started is added to DS0000000929.V353727.R01.S.doc Version 5.2 Page 27 2. 3. 4. OP7 OP9 OP9 5. OP9 Beverley Grange Nursing Home 6. OP19 the supplies on the medication record sheets. This should be done so as to ensure a running total is available at all times and an audit of stock is easy to carry out. The provider should consider the following areas for refurbishment: • The downstairs corridor carpets, which are marked and worn, • The pink lounge upstairs, where people have told us they do not like to sit as the décor is too bright and not appealing. • Various bath panels that are broken due to knocks from equipment and people during the bathing routines. The manager should make the bedrail risk assessments more robust by including better information about what the perceived risks are to warrant bed rails to be in place and that covers are to be fitted. Also, where people would be a greater risk if bedrails were put in place, what alternative measures are being taken to prevent people falling from their beds and sustaining injury. These risk assessments should be signed by the individual or their representative to show they have consented to this form of restraint. 7. OP22 Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Beverley Grange Nursing Home DS0000000929.V353727.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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