Inspection on 24/05/05 for Chatsworth Grange Nursing Home

This inspection was carried out on 24th May 2005.

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

Chatsworth Grange Nursing Home 10/01/09

Chatsworth Grange Nursing Home 03/12/07

Chatsworth Grange Nursing Home 27/02/07

Chatsworth Grange Nursing Home 08/11/05

Chatsworth Grange Nursing Home 06/10/04

Chatsworth Grange Nursing Home 18/05/04

Similar services:

Elmleigh Convent

Eastfield Farm Residential Home Limited

Cranwell Court Care Home

Fairview

Cottingham Hall

Cranmer Scheme

Fairburn Mews

Claremont House

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

CARE HOMES FOR OLDER PEOPLE Chatsworth Grange Nursing Home Hollybank Road Intake Sheffield S12 2BX Lead Inspector Claire McAuley Unannounced 24 May 2005 09:00 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 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. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Chatsworth Grange Nursing Home Address Hollybank Road Intake Sheffield S12 2BX 0114 2358000 0114 2358009 None Life Style Care plc Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Beverley Ann Furniss N Care home with nursing 66 Category(ies) of DE (E) Dementia - over 65 (66) registration, with number of places Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 6 October 2004 Brief Description of the Service: Chatsworth Grange is a purpose built nursing home registered for service users with dementia. The home is close to public transport, shops, public houses and churches. Chatsworth Grange provides 66 single rooms, all of which have ensuite facilities. The home is divided into four units which have their own lounge, dining, toilet and bathing facilities. The grounds are well maintained and a car park is provided. The home also provides an activities room, a hairdressing salon and a multi sensory room. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five hours from 9.00 to 14.00. Previous requirements were checked and a number of key standards assessed. A tour of the building took place. Some residents and a relative were able to express their views on the quality of care offered and five members of staff were also asked their opinions. A number of records were checked, and discussion with the manager took place. What the service does well: What has improved since the last inspection? What they could do better: Plans of care required more information on leisure and social needs of residents. Risk assessments on falls were not included in all plans of care. Moving and handling techniques needed to be reviewed. All staff should assist residents who need help with eating in an appropriate way. There should always be sufficient staff to help service users at mealtimes. Some dining areas, doors, doorframes and skirting boards required redecoration. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 Page 6 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. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 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 standard(s) 3 All residents have a full needs assessment undertaken to ensure the service is appropriate to meet their needs. EVIDENCE: Care plans seen contained a full needs assessment completed prior to their admission by an appropriate professional. These contained all the required information. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 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 standard(s) 7 8 10 Care plans were of a good standard, but required some improvement in recording leisure needs, and did not include one risk assessment on falls. Reviews required appropriate recording. Residents’ health needs were fully met. The residents were well cared for and their privacy and dignity was maintained. EVIDENCE: Plans of care were of a good standard and contained the majority of required information. Plans needed improvement in recording and reviewing resident’s leisure and social activities. It was not always clearly indicated if all areas in care plans had been updated. One plan did not have a risk assessment for falls, which was needed to protect the resident. Reviews did not always include resident’s relatives, as they did not always wish to take part. To ensure relatives are consulted and involved, recording on care plans should state that relatives have been invited to reviews and also include a record if they do not attend. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 Page 10 Resident’s health needs were met. The home had links with professionals including continence and pressure care nurses, Macmillan nurses, speech and language specialists, and psychiatrists. Residents received visits from their G.Ps, opticians chiropodists, and other healthcare professionals. The dentist visited six monthly as part of a new pilot scheme. Nutritional screening was undertaken for all residents, with food and fluid intake records in place. Residents at Chatsworth Grange suffer from dementia and it is difficult for them to express an opinion, although one resident said that staff were kind and looked after her/him well. Staff spoke to residents with respect and in a gentle and patient manner. Resident’s clothes were clean and smart and their choices of daily routines, food, and personal care were carefully maintained by staff who were able to use methods of communication appropriate to individual residents. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 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 standard(s) 12 14 15 Residents chose how to spend their day. There was a suitable range of activities provided. However residents would benefit by individual assessments of their leisure needs. Advocates were not available to residents at the home. A well balanced diet was provided which included special diets and residents choices. One service user was fed in an inappropriate way. EVIDENCE: Residents were encouraged to maintain their independence as much as possible, and choose how to spend their day. A range of activities was organised by the home’s activities coordinator. These included crafts, basketball, masseur, and baking. The home also had a multi-sensory room and activities room. Trips took place for residents who were able to take part in them. Staff said that residents often went out with them to shop in the local area, or to go to the nearby pub. A barge trip had been organised on the day of the inspection. Staff felt that residents would benefit by having more individualised assessments and activities organised for them which were then regularly reviewed to take account of their changing mental and physical condition. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 Page 12 Residents and their relatives did not have access to advocates, as the home was not aware of these services. There was a good range of food offered, including fresh vegetables and fruit. Resident’s preferences were catered for. The lunchtime meal was nutritionally balanced, and the majority of those who needed help were offered this in an appropriate way. A nurse who was standing over him/her was feeding a resident who was in bed, and this was not appropriate. There were a high number of residents who needed help with eating, and at times there were insufficient staff to help them. The cook was aware of special diets and liquidised food was attractively served. Drinks were served regularly throughout the day. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 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 standard(s) 16 18 The home had a complaints procedure which met the standards. No complaints had been received during the previous twelve months. Residents were protected from abuse by the homes policies and procedures. The majority of staff had received adult protection training. EVIDENCE: The complaints procedure was available for relatives at the entrance to the home. It was also in the service users guide. A relative said that he would speak to staff or the manager if he had any worries or complaints, but was happy with the service. Staff were aware of the complaints procedure. There had been no complaints at the home during the previous twelve months. The home had policies and procedures on adult protection. The majority of staff members were trained in Adult Protection, and were confident that they would report any potential abuse to the manager. Management were aware that any incidents of abuse should be reported to Social Services Adult Protection. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 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 standard(s) 19 25 26 The home was clean, fresh smelling, safe and generally well maintained. The building complied with the requirements of the fire service and environmental health department. Some areas required redecoration, and some chairs were damaged. The outside area of the home was safe and accessible to residents. For residents’ safety, water temperatures were maintained at the required level. Laundry facilities were appropriate and staff had training on the control of infection. EVIDENCE: All areas of the home were clean and generally well maintained. Furnishings and furniture were of a good standard, although some arms on chairs were damaged and a specialised chair was also damaged. There were some doors, skirting boards and doorframes which required redecoration. Three of the four dining areas also required redecoration. There was a maintenance and renewal programme in place. The outside garden area was enclosed and well maintained and accessible to residents. The building complied with the requirements of the fire service and environmental health department. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 Page 15 The water temperature records showed that the water temperature was maintained as required, ensuring the safety of residents. The home provided a pleasant environment for residents. The home had policies and procedures in place for the control of infection and staff had received training on this. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 28 29 30 Staffing rotas showed that agreed staffing levels were maintained. Sometimes there were insufficient staff to help at some mealtimes. (See standard 15). Recruitment files contained all of the required information, and CRB and POVA checks were carried out on all staff. Training for staff was comprehensive. The home had met the target of 50 of staff trained to NVQ2 or above. EVIDENCE: The staffing rotas showed that the home maintained the agreed staffing levels. Staff sickness and absence were covered by agency staff, and also by permanent staff working extra shifts. Staff spoken to said there were enough staff at the home except at times of sudden staff sickness and also at some mealtimes if there were a lot of residents who required help with eating. There was an appropriate gender and skill mix. The home had achieved its target of 50 of staff trained to NVQ2 or above. Recruitment files contained the full range of required information. For the safety of residents, staff did not start work at the home until CRB and POVA checks had been completed. A staff induction, training and development programme was in place that met NTO workforce training targets. Staff confirmed that they received regular training in order to meet resident’s needs. Training records were maintained for all staff employed at the home. Staff had not received specialised training on dealing with dementia. Residents would benefit from this. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 33 36 38 The home had an open and friendly environment, and there was positive leadership from the manager. There was a thorough quality assurance system which sought the views of those using the service, and ensured quality of care and the environment. Relatives were able to express their views through meetings. Staff supervision to ensure best practice took place, but was not always recorded. There was a health and safety policy in place to protect residents, staff and visitors. Moving and handling practice required revision. EVIDENCE: Staff members said that the home had an open and friendly environment and that the manager was supportive and approachable. There was positive leadership and a clear line of accountability. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 Page 18 The home had a thorough quality assurance system which sought the views of relatives, and (as much as possible) residents. Yearly questionnaires had been put in place and the results of the questionnaires had been published. There was a system of physical audits of the home, and quality monitoring, including level of staff sickness, accident monitoring, RIDDOR incidents etc. Regulation 26 visits to measure success in meeting the aims of the home were in place. Relatives meetings took place. These gave relatives/representatives the opportunity to receive information and express their opinions. Supervision at the home took place at the required level and helped staff to do their job, by including aspects of practice, philosophy of care and career development needs. This however, could not be verified, as supervision records were incomplete. Practical daily supervision of staff was also in place at the home. To protect residents staff and visitors to the home, there was a health and safety policy in place. Staff confirmed they had training in health and safety, moving and handling, fire safety, first aid, and infection control. One staff member transferred a resident to a chair using an inappropriate manoeuvre. When the building was checked no fire exits were blocked, fire doors closed on their rebates and hazardous substances were securely stored. The manager said boilers, central heating systems, electrics, and other equipment had been checked/serviced. There were appropriate measures in place to ensure the security of the premises and prevent intruders. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 2 15 2 COMPLAINTS AND PROTECTION 2 x x x x x 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 3 3 x x 2 x 2 Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 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. 3. Standard 7 7 7 Regulation 15 15 15 Requirement Recording of leisure and social needs on plans of care should be detailed and regularly reviewed. Risk assessments on falls and prevention of falls must be included in all plans of care. Plans of care must indicate if relatives or representatives of residents have attended reviews or not. Residents and relatives/representatives must be able to access advocacy services. Staff must not stand over residents to feed them. All staff must have training in adult protection. The damaged chair must be repaired or replaced. The chairs with damaged arms must be repaired or replaced. The identified door frames, doors, and skirting boards must be redecorated. The three dining areas must be redecorated. There must be sufficient staff employed at the home to help residents appropriately at all mealtimes. Timescale for action 1st September 2005 1st August 2005 1st August 2005 1st September 2005 Immediate 24th May 2005 1st August 2005 1st September 2005 1st September 2005 1st August 2005 4. 14 12 5. 6. 7. 15 18 19 18 12 18 13 16 8. 19 23 9. 27 12 Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 Page 21 10. 11. 36 38 18 13 All formal supervisions must be recorded. All staff must receive training on appropriate moving and handling techniques. Supervision of staff when in the process of moving and handling must be reviewed. 1st September 2005 Immediate 24th May 2005 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. 2. 3. Refer to Standard 7 12 30 Good Practice Recommendations The care plans should clearly indicate when they have been updated. Further work should be undertaken to provide individual activities for residents. Training on all aspects of dementia care should be offered to all nursing and care staff. Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Ground floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR 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 Chatsworth Grange Nursing Home J55 S21774 Chatsworth Gge V218751 240505 UI Stage 4.doc Version 1.30 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!