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Inspection on 06/12/05 for Beverley Grange Nursing Home

Also see our care home review for Beverley Grange Nursing Home for more information

This inspection was carried out on 6th December 2005.

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

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

Relatives are assisted in supporting the resident in accessing the home. One relative commented, "It is not just basic care, it`s the extras you get. The care, not only to the person but also to the family is very special." Service users are happy with the care provided. One service user commented " Plenty of care from staff. Staff are very kind and quite understanding."

What has improved since the last inspection?

Call bell facilities and drinking water are now within easy reach of the service users, assisting in ensuring their needs can be met. The recruitment procedures for staff now ensures that a Criminal Records Bureau (CRB) check is completed, protecting the service users.

What the care home could do better:

The home has admitted one resident for whom the home is not registered to provide care for and this could jeopardise the care provided to the other service users.

CARE HOMES FOR OLDER PEOPLE Beverley Grange Nursing Home Lockwood Road Molescroft Beverley East Yorkshire HU17 9GQ Lead Inspector Sarah Sadler Unannounced Inspection 6th December 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 Beverley Grange Nursing Home DS0000000929.V271143.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. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beverley Grange Nursing Home Address Lockwood Road Molescroft Beverley East Yorkshire HU17 9GQ 01482 679955 01482 679770 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.V271143.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Nursing care for one service user under 65 years Registered for 2 day places for patients over 55 years of age. One bed for young and disabled Date of last inspection 3rd August 2005 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. The home was opened in 1999 to cater for long term and respite care, catering for people who need residential care or nursing care. 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. 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. The home is registered for 64 people. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken over 4.5 hrs by one inspector. The inspection was part of the annual inspection programme from April 1st 2005 to March 31st 2006. During the inspection a tour of the premises was undertaken, residents, and members of staff were spoken to. An amount of time was spent with residents, observing their everyday life. Some time was spent reading resident and other records within the home. What the service does well: What has improved since the last inspection? What they could do better: Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 6 The home has admitted one resident for whom the home is not registered to provide care for and this could jeopardise the care provided to the other service users. 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.V271143.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 Beverley Grange Nursing Home DS0000000929.V271143.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): 1,2,3,6 Service users are provided with information regarding the home, which will assist them in their decisions prior to moving to the home. Service users are not always assessed prior to moving into the home, to ensure that the home can meet their needs. Intermediate care is not provided by the home. EVIDENCE: The registered manager confirmed that the statement of purpose and service user guide has been amended. Both documents cover many of the required areas, for example information regarding the registered manager. The information not yet included was discussed with the registered manager. Copies of the service user guide were in situ in the majority of service users’ rooms. One service user questioned stated that they ‘were not interested’ in reading this information and were happy in the home. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 9 The registered manager confirmed that intermediate care is not provided within the home. The registered manager confirmed that one service user continues to be placed out of the categories that the home is registered for, but that this person is due to move shortly. A large storage rack in the entrance foyer now holds a variety of information regarding different advocacy and support groups that may be accessed by service users or their representatives. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 10 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): 8,9 Service users’ health needs are not always met by the home. EVIDENCE: Service users were relaxed within the home. Service users in their rooms had call bells and drinks within easy reach. One service user had the curtains drawn to prevent the sunlight disturbing them. There is a risk assessment in place regarding the service user who is placed out of category and their needs. However this document is very limited and the registered manager was advised as to the necessity to develop this further. An illness recently notified to the commission has not yet been treated. The home has received advice regarding this from the local health protection nurse. However there have been difficulties in attaining the recommended medications from the GP. The registered manager was advised as to the necessity for the urgent rectifying of this situation. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 11 Records for the administration of medicines were found to be up to date and correct. Although health records attached to these were not always completed, for example, the recording of blood sugar levels for those people with diabetes. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 12 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): None of these standards were assessed at this inspection. EVIDENCE: Residents confirmed that they have visitors as they wish. “My brother and relations visit and can come anytime”. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 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 Service users are able to complain and this will be acted upon. EVIDENCE: Records are kept of complaints, the actions taken and where possible the outcome of the complaint, including if the complainant is happy with the outcome. There is one ongoing complaint that has been referred to the Local Authority. The registered manager has investigated this and is awaiting feedback from the complainant to ascertain if they are happy with the investigation results. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 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): 19,26 Service users live in a comfortable home. The procedures for infection control do not protect service users. EVIDENCE: The home remains well decorated and maintained. Service users have been involved with the Christmas decorations and these add to the ambience of the home. Service user rooms continue to be personalised by the service users, reflecting their individual personalities. A health need has not been addressed quickly and this has placed service users at the increased risk of infection. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 15 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): 28,29,30 Service users are supported by a staff team who are on the whole appropriately recruited and trained. EVIDENCE: Staff files all included Criminal Record Bureau (CRB) checks and copies of the General Social Care Councils (GSCC) code of conduct. The registered manager confirmed that nearly all staff now holds a copy of this. The file of a recently appointed nurse did not include details of the verification of the PIN number confirming that the nurse was registered to practice. The registered manager confirmed that 48 of the care staff team now hold a National Vocational Qualification (NVQ) level 2 or equivalent in care and that a further 25 of the remaining staff team are working to achieve this qualification. The registered manager confirmed that some staff have undertaken dementia care training and that it is planned in the New Year that more staff will attend this. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 16 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): 31,37 Service users live in a home that is on the whole well managed. EVIDENCE: The registered manager is a registered general nurse and she confirmed that she has attained the Registered Managers award and has undertaken other management training over the last year. Service user files contain all of the documents required within schedule 3, except a photograph. Visits by the registered person as required by regulation 26 now take place on a monthly basis and the written reports from these visits are kept within the home. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 17 There are monthly staff meetings, which are divided into the individual staff groups, for example upstairs and downstairs, domestic. A three monthly general staff meeting complement these. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 18 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 1 X N/A X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 1 9 3 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 3 17 X 18 X 4 X X X X X X 1 STAFFING Standard No Score 27 X 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X 1 X Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 19 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. Standard OP1 Regulation 4, 5 ,6 Requirement Timescale for action 03/08/05 2. OP3 3 OP8 4 OP8 5 OP8 6 OP29 The statement of purpose and service user guide must adequately reflect conditions in the home. This is an ongoing requirement with a previous compliance date of 3/08/05. 10 The registered person must ensure that service users admitted to the home are appropriate to their registration category. This is an ongoing requirement with a previous compliance date of 03/08/05. 12,13,14 The registered person must ensure that residents’ health needs are met. With all appropriate records kept. 12,13,14 The registered person must ensure that service user illness is treated within an acceptable timescale. 12, 13, 14 The risk assessment must be sufficiently detailed to guarantee the homes ability to ensure the safety of residents in the home, in the light of one admission inappropriate to the homes category status. 19 The registered person must DS0000000929.V271143.R01.S.doc 03/08/05 15/12/05 15/12/05 15/12/05 30/12/05 Page 20 Beverley Grange Nursing Home Version 5.0 7 OP37 17 ensure that all relevant checks are completed prior to the employment of any nurse. Evidence of this must be available to inspection. The records outlined in schedule 31/08/05 3 must be held in respect of each service user. This is an ongoing requirement with a previous compliance date of 31/08/05. 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 OP1 Good Practice Recommendations Staff should ensure that service users have an understanding of the facilities available in the home. Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beverley Grange Nursing Home DS0000000929.V271143.R01.S.doc Version 5.0 Page 22 - 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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