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Inspection on 03/12/07 for Chatsworth Grange Nursing Home

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

This inspection was carried out on 3rd December 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.

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

People living in the home said that the care they were receiving was good. They made comments such as: "Staff are lovely". "Everything is lovely". "They`re all very kind". Comments received from questionnaires and from talking to relatives were positive and included: "We are very happy with the residence and service provided". "The home gives mum a quality of life relevant to her disability". "It is a friendly well run home which mum enjoys being part of". "We are very happy with the home and cannot think of any way it can improve to support my mum". Health professionals said: "The staff are always polite and helpful" "The residents well cared for". Care plans were in place for all. They set out all aspects of personal, social and health care needs and recorded the staff action required to ensure all identified needs were met. People`s health care was monitored and access to health specialists was available. People and relatives confirmed that staff were always respectful towards them. People said they enjoyed the activities available at the home. Activities available included baking, arts and crafts, reminiscing and massage. People also spoke about their trips outside the home to the tea dance, local pub and theatre. People said that they had a choice of food and that the quality of food served was "alright", "good" and "appetising". There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. The home was clean and tidy. No unpleasant odours were noticeable in the home. People living in the home and their relatives said that the home was always kept "sweet smelling" and "very tidy". Training took place, to equip staff with the essential skills needed. Systems were checked and serviced to maintain a safe environment.

What has improved since the last inspection?

All requirements and recommendations issued at the previous inspection had been actioned. The manager and staff at the home should be commended for this. Staff had worked hard to improve medication administration procedures. All medications were accurately recorded. Medications that were not supplied in monitored dosage were checked daily. All handwritten changes to MAR sheets were signed. This helped to ensure that medication administration was safe. Staff were not recruited prior to an appropriate POVA first check and CRB disclosure being received. All recruitment checks and procedures were being adhered to. Thermometers had been placed in all refrigerators. Where `safety gates` were placed on a bedroom door, an individual risk assessment had been put in place. Nurses and carers were given supervision to support and give guidance on an individual basis.

What the care home could do better:

So that people`s health, safety and comfort are maintained, when eating and drinking they must be seated in a position that helps them to eat and swallow at ease. To ensure that people`s needs are being consistently met, sufficient staff should be on duty at all times. A process of risk assessment should be carried out for staff that are employed following receipt of an unclear CRB check. Decisions taken should be recorded in writing and placed on their file. To ensure peoples health and safety, fire alarms should be tested every week. Activities, ancillary and kitchen staff would benefit from being offered formal supervision.

CARE HOMES FOR OLDER PEOPLE Chatsworth Grange Nursing Home Hollybank Road Intake Sheffield South Yorkshire S12 2BX Lead Inspector Sue Turner Key Unannounced Inspection 3rd December 2007 08:00 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 Chatsworth Grange Nursing Home DS0000021774.V355669.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.V355669.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 chatsworthgrange@schealthcare.co.uk www.schealthcare.co.uk Southern Cross (LSC) Ltd 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) 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.V355669.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user under the age of 65 named on variation dated 6th September 2006 may reside at the home. 27th February 2007 Date of last inspection Brief Description of the Service: Chatsworth Grange is a purpose built nursing home registered for people with dementia. The home is close to public transport, shops, public houses and churches. Chatsworth Grange provides 66 single rooms, all of which have en-suite 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. The home has a Statement of Purpose and a Service User Guide which was displayed in the home and available to people and their relatives. A copy of the previous inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of monthly fees from 1st April 2007 were £474.00 - £550.54 per week. Additional charges included newspapers, hairdressing and private chiropody. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Sue Turner regulation inspector. This site visit took place between the hours of 8.00 am and 3:15 pm. Beverley Furniss is the registered manager and was present during the visit. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people staying in the home, their relatives and any professionals involved in peoples care. The Commission for Social Care Inspection (CSCI) received one questionnaire from a person using the service, one from a relative and two from professionals. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to eleven staff, one volunteer, six relatives and three people. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in February 2007. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well: People living in the home said that the care they were receiving was good. They made comments such as: “Staff are lovely”. “Everything is lovely”. “They’re all very kind”. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 6 Comments received from questionnaires and from talking to relatives were positive and included: “We are very happy with the residence and service provided”. “The home gives mum a quality of life relevant to her disability”. “It is a friendly well run home which mum enjoys being part of”. “We are very happy with the home and cannot think of any way it can improve to support my mum”. Health professionals said: “The staff are always polite and helpful” “The residents well cared for”. Care plans were in place for all. They set out all aspects of personal, social and health care needs and recorded the staff action required to ensure all identified needs were met. People’s health care was monitored and access to health specialists was available. People and relatives confirmed that staff were always respectful towards them. People said they enjoyed the activities available at the home. Activities available included baking, arts and crafts, reminiscing and massage. People also spoke about their trips outside the home to the tea dance, local pub and theatre. People said that they had a choice of food and that the quality of food served was “alright”, “good” and “appetising”. There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. The home was clean and tidy. No unpleasant odours were noticeable in the home. People living in the home and their relatives said that the home was always kept “sweet smelling” and “very tidy”. Training took place, to equip staff with the essential skills needed. Systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 7 All requirements and recommendations issued at the previous inspection had been actioned. The manager and staff at the home should be commended for this. Staff had worked hard to improve medication administration procedures. All medications were accurately recorded. Medications that were not supplied in monitored dosage were checked daily. All handwritten changes to MAR sheets were signed. This helped to ensure that medication administration was safe. Staff were not recruited prior to an appropriate POVA first check and CRB disclosure being received. All recruitment checks and procedures were being adhered to. Thermometers had been placed in all refrigerators. Where ‘safety gates’ were placed on a bedroom door, an individual risk assessment had been put in place. Nurses and carers were given supervision to support and give guidance on an individual basis. What they could do better: So that people’s health, safety and comfort are maintained, when eating and drinking they must be seated in a position that helps them to eat and swallow at ease. To ensure that people’s needs are being consistently met, sufficient staff should be on duty at all times. A process of risk assessment should be carried out for staff that are employed following receipt of an unclear CRB check. Decisions taken should be recorded in writing and placed on their file. To ensure peoples health and safety, fire alarms should be tested every week. Activities, ancillary and kitchen staff would benefit from being offered formal supervision. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 8 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. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 9 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.V355669.R01.S.doc Version 5.2 Page 10 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): Standards 1, 3, 4 and 5. Standard 6 is not applicable to this home. 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 provided sufficient updated and relevant information to inform people about their rights and choices. Trial visits were encouraged to enable people to look around the home, meet other people living there and give them the information needed to make informed choices. EVIDENCE: The homes Statement of Purpose was available and on display in the entrance hall. When people showed an interest in the home they were provided with an information pack. This contained the Service User Guide, the homes brochure and a copy of the menus and activities on offer. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 11 The manager or her deputy carried out a pre assessment so that they could be assured that they could meet the person’s needs. People were invited to visit the home and spend time meeting the staff and seeing the services available. This home does not provide intermediate care services. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 12 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): Standards 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. People’s health, social and personal care needs were documented in the care plans and a range of health care professionals visited the home, which meant that individual needs could be met. Medication procedures protected people’s health and welfare. People and their relatives were complimentary about the way staff promoted their privacy and dignity. EVIDENCE: People living in the home had an individualised plan of care. Three peoples plans of care were checked. Care plans contained a full range of information. These contained specific information on all aspects of personal, social and health care needs. People and their relatives were encouraged to be involved in the planning of care. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 13 Relatives said: “Although I only see a snapshot of my mothers care when I visit twice a week the impression I get is very positive”. “I think mother gets the level of care that I expect, especially the physical aspects”. “We know that we can look at mums care plan if we wish. We have also been involved in the care planning when mum first came to the home”. The care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. People said that GP’s, dentist, opticians and chiropodists visited the home as requested. Relatives said: “If mother is in discomfort staff always respond”. “I would like more feedback in regard to my mothers condition or changes to her physical/mental state, without having to ask”. “Staff are very good at letting me know if my uncle has had a fall etc”. “I am always contacted if my wife is unwell”. Staff were regularly reviewing and updating individual risk assessments and care plans. Medicines were securely stored around the home in locked trolleys within cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Qualified nurses administered medications. There was evidence that managers and trained staff were auditing medication administration procedures. Controlled drugs (CD) were kept in a clinical room and within a double locking cabinet. People and relatives spoken with, and via their questionnaires, confirmed that the carers treated them with respect and provided personal care and support in a way that maintained their dignity and privacy and was sensitive to their individual needs and wishes. Staff were observed speaking to people in a respectful way and showed empathy and patience when providing personal care to them. Chatsworth Grange Nursing Home DS0000021774.V355669.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): Standards 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 had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. A range of activities was on offer, which promoted choice and maintained interests. Meals served at the home were of a good quality and offered choice, which ensured people received a healthy balanced diet. EVIDENCE: People were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. The inspector saw that everyone coming to the home was made to feel comfortable whilst visiting their loved one. Weekly activities were displayed in the entrance hall. The home employed an activities worker and an assistant who worked each day. Examples of the activities available were crafts, baking, exotic fruit tasting and reminiscing sessions. The home has its own “Woolpack” pub, which was used by people Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 15 and their relatives as a meeting place. Outside entertainers visited the home and trips to the coast, shopping centres and the theatre were regularly organised. Relatives said: “I sometimes think mother would benefit from increased interaction/companionship with/from staff and other residents”. “Mum doesn’t get involved in the activities but loves it when an entertainer comes along. It would be better if more outside entertainers visited”. “I enjoy spending time with my relative in the Woolpack”. People said that the meals at the home were “ no problem”, “good” and “fine”. Menus were rotated on a four weekly basis. Choices were always available. The head cook had implemented a well balanced diet and was in the process of introducing the ‘Nutmeg’ system. This used the traffic light colours to identify that meals were nutritionally sound. The inspector observed people during breakfast and lunch. Dependency levels at the home were very high and many people needed help to eat. Staff were seen assisting people in a caring and supportive way. Meals were not rushed. Meals were not served to people until there was someone available to support them. In one dining room three people were in ‘easy chairs’ and seven people sat at tables, six of which were in wheelchairs. A number of people were not sitting upright to the table, which was making it more difficult for them to eat. Some people were eating soft or liquidised diets due to swallowing difficulties. The sitting position of people could have added to their difficulties. People were able to bring personal items with them into the home. All of the bedrooms seen were individually personalised, spacious and homely. Chatsworth Grange Nursing Home DS0000021774.V355669.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): Standards 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. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced would be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected. EVIDENCE: People and their families had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall and bedrooms. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. Relatives spoken to said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes. The home had received eighteen complaints since the last inspection. Fifteen of the complaints were in relation to payment of fees. When Southern Cross became the new owner there were difficulties in the changeover for payment of fees, which resulted in many people being Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 17 unhappy. This had been rectified and people had received an apology from the organisation. Three complaints received; about care issues had been investigated by the registered manager and any appropriate action taken as necessary. CSCI had not received any complaints about the home. Staff spoken to were clear how to respond and record any complaints received. Relatives said: “Whenever I mention things to staff they always try to put it right, if they didn’t I would speak to the manager”. “I talked to the manager about one concern she listened and then sorted it out”. An adult protection procedure was in place. Staff had undertaken formal training on adult protection, which had equipped them with the skills needed to respond appropriately to any allegations. People spoken to said that they felt safe living at the home. One relative said: “If there was a better home in Sheffield then my wife would be living in it”. Chatsworth Grange Nursing Home DS0000021774.V355669.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): Standards 19, 24 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 home was well maintained, clean and fresh smelling. Homely touches had been provided to create a comfortable environment. Controls of infection procedures were in place, which promoted people’s health and welfare. EVIDENCE: The home was clean and tidy. Lounge and dining areas were domestically furnished. A tour of the building identified that some areas of the home were in need of minor repair. A handy person was employed to help maintain the environment. Homely touches were provided, which enhanced the feeling of warmth and wellbeing. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 19 Bedrooms checked were cosy. Some people spent a lot of time in their rooms, their beds were comfortable, bed linen was clean and in a good condition. The manager had a programme of refurbishment and redecoration that ensured that the home was aesthetically pleasing and free from hazards. The manager said that the provider would carry out any work that she deemed necessary for the comfort and well being of the people living in, working and visiting the home. Planned decoration at the home was taking into consideration the new dementia strategy principles. Doors to bedrooms were being painted in dominant colours, had doorknockers, letterboxes and individualised nameplates. Relatives said: “The home is clean and mostly sweet smelling”. “Mum has everything that she needs in her room”. Controls 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.V355669.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Due to the high dependency needs of people when staffing levels are at minimum, staff find it difficult to maintain the high standard of care expected at the home. Recruitment procedures promoted the protection of people. Staff had completed training that ensured they had the competences to meet people’s individual needs. EVIDENCE: Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. Staff raised concerns about staffing levels not being adequate when sickness had to be covered. They said they were willing to work extra hours to help out, but said they shouldn’t feel that they had to do this. One relative raised concerns about staff numbers being low when staff were attending training. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 21 Another relative said: “Staff work hard and are busy, I often look around and think there ought to be more staff”. Considering the dependency levels of the people living in the home the inspector believes that when staffing levels are at minimum it is difficult to provide the individualised care required by individuals. The inspector acknowledges that there are shifts when staffing levels are above minimum requirements. One relative said: “A proportion of the staff have some language issues which make it difficult for mother to understand”. One professional said: “Sometimes staff are difficult to understand, this has improved lately”. One staff questionnaire said: “Staff do not always work as a team” and “there is a lack of communication between staff”. Staff were asked about teamwork and communication and all those spoken to said they thought that this was one of their strengths and something that they did particularly well. Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving and Handling, Food Hygiene, Adult Protection, First Aid and Fire. Staff said they had received training in customer care. This included the preservation of dignity, maintenance of privacy, freedom of choice, respect and independence. 68 of the care staff had achieved NVQ Level 2 in Health and Social 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. The recruitment records of three employed staff members were checked. The staff had provided employment histories and the home had obtained two written references for each of them. These were satisfactory. Protection Of Vulnerable Adults (POVA) checks had been made and Enhanced Criminal Record Bureau (CRB) checks had been obtained for the staff members. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 22 One person’s file recorded that the CRB check had highlighted a criminal offence. The manager said that she was aware of this and had made the decision to employ the person, following a discussion with the operations manager. There was no information on file to confirm that a process of risk assessment had been followed. Chatsworth Grange Nursing Home DS0000021774.V355669.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): Standards 31, 33, 35, 36, 37 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 manager’s leadership approach benefited people and staff. Quality assurance systems meant that the home was run in the best interests of everyone. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. In the main people’s health and safety had been promoted and protected. EVIDENCE: The registered manager was hard working, competent and carried out her role to a high standard. She was clearly committed to ensuring that people living in the home were consistently well cared for, safe and happy. The registered Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 24 manager holds a weekly “managers surgery”. This gave people and relatives the opportunity to meet with her out of normal office hours. Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. Monthly monitoring visits by the responsible individual took place. Records of these visits covered all aspects of the home. The manager had many ways in which to check out the quality of the service that they were providing. Regular staff and relative meetings were arranged. The home carries out yearly satisfaction surveys, copies of these were on display and comments had been acted upon. A monthly newsletter kept relatives informed of developments in the home. These were placed in bedrooms for people to see and read. The home handles money on behalf of some people. Account sheets were kept, receipts were seen for all transactions. Formal staff supervision, to develop, inform and support staff took place at regular intervals. Staff said that they found this useful and beneficial. Activities, ancillary and kitchen staff were not offered supervision, although they were able to speak to their line manager about any issues etc. The inspector believes that they would benefit from the same formal supervision offered to the nurses and carers. Equipment at the home was serviced and maintained. Fire records evidenced that fire alarm checks took place, but could sometimes miss a week, if the handyman was on holiday. This was not in line with the fire services recommended ‘weekly’ check. Staff said fire drill training took place on a regular basis and the inspector saw evidence of this. The company employed a person who was responsible for completing the fire risk assessment. The manager confirmed this was completed and there were no outstanding areas of concern. Chatsworth Grange Nursing Home DS0000021774.V355669.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 3 X 3 3 3 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 2 Chatsworth Grange Nursing Home DS0000021774.V355669.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. 1. Standard OP15 Regulation 13 Requirement When people are eating and drinking they must be seated in a position that helps them to eat/swallow comfortably and safely. Sufficient staff must be on duty at all times to ensure that people’s needs are being consistently met. Timescale for action 03/12/07 2. OP27 18 03/12/07 3. OP30 19 4. OP38 23 (4) (c) (v) A process of risk assessment 03/12/07 must be carried out for staff that are employed following receipt of an unclear CRB check. Decisions taken must be recorded in writing and placed on their file. Fire system checks must be 03/12/07 carried out weekly. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 27 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 Activities, ancillary and kitchen staff should be offered supervision at the recommended intervals. Chatsworth Grange Nursing Home DS0000021774.V355669.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. 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