Inspection on 27/02/07 for Chatsworth Grange Nursing Home

This inspection was carried out on 27th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chatsworth Grange Nursing Home 10/01/09

Chatsworth Grange Nursing Home 03/12/07

Chatsworth Grange Nursing Home 08/11/05

Chatsworth Grange Nursing Home 24/05/05

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 South Yorkshire S12 2BX Lead Inspector Mr Rob Curr Key Unannounced Inspection 27th February 2007 08:30 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 Chatsworth Grange Nursing Home DS0000021774.V303493.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. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chatsworth Grange Nursing Home Address Hollybank Road Intake Sheffield South Yorkshire S12 2BX 0114 235 8000 0114 235 8009 none 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) Life Style Care Plc Mrs Beverley Ann Furniss Care Home 66 Category(ies) of Dementia - over 65 years of age (66) registration, with number of places Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 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. In January 2007 the fees ranged £462.00 to £471.87. The services Statement of Purpose is provided to each service user and the last inspection report was available from the office. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. The site visit was from 8.30 am until 5.30 pm. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, complaints, rotas, staff training and recruitment and fire records. A number of care staff and nurses were spoken to about their skills and experiences of working at the home. Discussions took place with the registered manager and an Operations Manager of the company. A number of residents were interviewed along with four relatives. The inspector would like to thank the manager and her staff team for their support during the inspection process. What the service does well: What has improved since the last inspection? Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 6 50 of the care staff have achieved NVQ level 2 or higher in ‘Care’. A large number of chairs have been purchased for around the home and the decorating schedule has continued. 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. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Standard 6 was not applicable. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. Residents’ needs were assessed prior to admission. Residents and their relatives were fully involved in the assessment and admission process, so this ensured that the home was able to meet their needs. The manager did not offer places to any individual whose needs they could not meet. The staff-training plan was on target. EVIDENCE: Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 9 Copies of full need assessments were in the residents files. All the relevant information from the assessments had been built into the care plan. Two relatives said that they had been invited to view the home and attend a variety of meetings prior to their relative moving into the home. Staff training records indicated that they had undertaken relevant training required to assist them in caring for the people that reside at Chatsworth Grange. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 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): 7, 8, 9 and 10. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. Each resident had a plan of care, to inform staff of the actions required to meet assessed need. Records indicated that residents’ health care was monitored, to maintain health. The recording and administration of medication was well managed, to promote residents safety, although there some minor errors relating to recording in the medication sheets. Interactions observed between residents and staff evidenced that resident’s privacy and dignity was respected. Written policies and procedures were in place regarding dying and death, to ensure residents and their relatives were supported sensitively. EVIDENCE: Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 11 A number of care plans were examined. Some sections of the care plans seen were comprehensive and contained detail of the staff action required to ensure needs were met, for example, methods of communication. Care plans contained information on contacts with health care professionals, such as general practitioners and specialist nurses. There were a number of residents being care for in their bedrooms. On meeting these residents it was observed that they all had the appropriate support in terms of general health care and personal hygiene. The plans contained records of health assessments, such as moving and handling and skin integrity. Nutritional assessments were undertaken. Residents and visitors said that health care needs were met. Qualified staff administered medication. Part of a medication administration round was observed; medication appeared to be administered correctly and safely although the following issues were noted. • • • • There were handwritten changes to numbers on medication labels Medication had not been administered in line with instructions Medication that had been discontinued was still on MAR sheets Handwritten Mar sheets were not signed Medication was stored securely and all medication administration records were fully completed. Staff were observed to respect service users privacy by closing bathroom and bedroom doors. They were also seen to knock on doors before entering. Residents were able to choose whether to spend time in their rooms, or in communal areas. Peoples preferred form of address was respected. One resident said that he had complex needs and that new members of the staff team were never allowed to support him until they had the appropriate induction. He felt that this upheld his privacy and dignity. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 12 Staff promptly responded to residents that became anxious in a kindly, reassuring and patient manner. One relative said that ‘staff are always patient with my mother’. A policy and procedure were in place regarding dying and death. Relatives spoken with on the day confirmed that they were kept informed of their loved ones health. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. Activities were provided to residents by a co-ordinator and invited entertainers, to improve choice and quality of life. The routines at the home were flexible and service users were in the main able to choose how to spend their time, in line with health and safety and assessed risk, to maintain and improve the quality of life. An open visiting policy was in operation, in order to develop and maintain good relationships with resident’s representatives. Contact with relatives and friends was supported. The homes menu was varied, and special diets were catered for, to meet residents’ needs and maintain health. The catering team were very committed to providing a choice of menu, supporting any resident that has individual likes and dislikes. EVIDENCE: Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 14 Three residents said that the ‘entertainment was good’, ‘we always know what’s happening’. Residents were seen to walk freely around the home. A visitor spoken with said ‘I am always made to feel welcome, and have no concerns at all about the care of my mother, I am very happy with the care provided’. Staff supported residents choices, and were overheard to offer individuals choice of breakfast. The homes menu was varied and choices were offered. One resident spoken with said the food was ‘very good’. Staff sat with the residents that required assistance with eating, and this support was given patiently and respectfully. Whilst one member of staff was assisting a person with their meal the other members of staff were supporting the remaining residents. The inspector noted that a number of people required assistance with taking meals. The cook and her team were clearly aware of individual residents special dietary requirements. The cook had recently undertaken an awareness day in relation to the dietary needs of people with varying forms of dementia called ‘Food for Thought’. The cook stated that she had found this training to be most useful and could relate most of the information to her work with older people. There were plentiful stocks of food, which staff had access to, to provide snacks and drinks during the evening and night, if required. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 15 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 and 18. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened and responded to. An adult protection procedure was in place. Staff were fully aware of these procedures, to ensure residents safety was promoted. EVIDENCE: The complaints procedure was on display in a communal area of the home. This procedure informed residents and their representatives of the providers approach to complaints. A record of complaints was kept. Complaints had been received sine the last inspection – these had been handled well and the outcome was recorded. The staff spoken with were clear about the procedures to undertake in regard to adult protection and about the homes complaints procedure. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 16 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. The home was clean and generally well maintained, to provide a pleasant environment for residents. Controls of infection procedures were in place, to promote resident’s health and safety. EVIDENCE: A tour of the building identified that some areas of the home were in need of minor repair. The manager had highlighted these to the inspector and the repairs had been identified in the maintenance book. There was inappropriate storage within some bathrooms. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 17 Some homely touches were provided to create a comfortable environment for the residents. A maintenance person was employed to help maintain the environment. A rolling programme of redecoration and replacement was in place. Control of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. Sufficient staff were provided to meet the needs of residents. The required levels of NVQ trained staff had been achieved. The recruitment policies and procedures were not followed consistently. These practices do not ensure that staff are suitable for the post. A comprehensive range of training was provided to all staff, to improve their skills and enable them to support residents effectively. EVIDENCE: The rota evidenced that appropriate levels of staff were being maintained. Three residents spoken with said that there were enough staff provided. Two visitors spoken with said they were happy with the levels of staff. The home had recruitment systems in place to protect residents, however, the following issues were noted within the files checked: • • • Application forms had not been fully completed Full employment histories had not been provided One member of staff had been recruited prior to a criminal record bureau disclosure or a Pova check. DS0000021774.V303493.R01.S.doc Version 5.2 Page 19 Chatsworth Grange Nursing Home Twenty-four care staff had achieved NVQ Level 2 or above in care. A number of care staff had also commenced the training. This clearly met the required minimum of 50 of the staff team trained to NVQ Level 2 in Care. Induction and ongoing training were provided to staff. The manager had worked hard to maintain training records and ensure appropriate training was available to staff. A training matrix and individual training records were maintained, to assist in monitoring the training provided. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 20 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, 32, 33, 35, 36, 37 and 38. Quality in this outcome area was good. This judgement has been made using available evidence, including a visit to the home. There was a very positive style of management in the home. This clearly benefits the residents and their relatives and representatives. There was a quality assurance system in place, which gave residents and visitors an opportunity to express their views and suggest ways in which the service may be improved. Staff supervision systems were in place to ensure best practice was maintained although they were not up to date. All records were securely stored. Health and safety hazards were identified; this did not ensure residents were safe. All staff had undertaken fire training. EVIDENCE: Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 21 Staff said that the manager was approachable and supportive. The manager had an annual plan that identified and prioritised areas for improvement, to enhance the service provided. The ‘quality assurance questionnaire report’ was available to inform relatives and other interested parties, the current views of the service. Care staff and nurses said that the frequency of their supervision sessions had lessened, although they acknowledged that this could be due to staff sickness and annual leave. Fire records were maintained of fire alarm tests. The fire drill records indicated that staff (including night staff) had undertaken a fire drill practice within the last year. The refrigerator on ‘Tansley’ did not have a thermometer for testing for safe temperatures. ‘Safety gates’ were used on resident’s bedrooms doors. In the files checked, there were no individual risk assessments to indicate the reason for the use of the gates and to highlight who had been part of making the decision. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 22 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 2 Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13 Requirement All medication administration must be accurately recorded. (Previous timescale of 08/11/05 not met) Handwritten changes to medication records must be kept to a minimum All handwritten changes to MAR sheets must be signed Bathrooms must not be used for storage. Under no circumstances must staff be recruited prior to an appropriate Pova first check and CRB disclosure being received. All recruitment procedures must be adhered to. A thermometer must be placed in the identified refrigerator. When ‘safety gates’ are placed on a service users bedroom door, an individual risk assessment must be in place. Timescale for action 24/04/07 2 3 4 5 OP9 OP9 OP20 OP29 13 13 13 Sch 2 24/04/07 24/04/07 24/04/07 24/04/07 6 7 8 OP29 OP38 OP38 Sch 2 13 13 24/04/07 24/04/07 24/04/07 Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 24 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 OP36 Good Practice Recommendations All staff should be offered supervision at the recommended intervals. Chatsworth Grange Nursing Home DS0000021774.V303493.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sheffield Area Office 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. 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