Inspection on 08/11/05 for Chatsworth Grange Nursing Home

This inspection was carried out on 8th November 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 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 27/02/07

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 Mrs Claire McAuley Unannounced Inspection 8th November 2005 08.45 X10015.doc Version 1.40 Page 1 X10015.doc Version 1.40 Page 2 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.V270458.R01.S.doc Version 5.0 Page 3 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.V270458.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Name of service Chatsworth Grange Nursing Home Address Hollybank Road Intake Sheffield South Yorkshire S12 2BX 0114 235 8000 0114 235 8009 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.V270458.R01.S.doc Version 5.0 Page 5 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 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. Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place from 8.45 to 14.00. Previous requirements were checked and key standards not assessed at the inspection of 24th May 2005 were checked. A proportion of the environment was inspected. The majority of residents were unable to express their views on the care offered by the home because of their mental condition. Three relatives were interviewed on the quality of care, and three 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: Staff members felt that there were still insufficient staff to help residents at mealtimes, and also felt that the high dependency levels of the residents required more staff on duty. The activities co-ordinator required more assistance from staff, when undertaking activities with residents. Staff supervision did not take place at the required level for some staff, and recording of supervision was not complete. Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 Page 7 Some areas of the home were in need of redecoration, including corridors, doorframes, dining areas, and some residents bedrooms. Some carpets were stained and required cleaning. There were a number of errors in the recording of medication administration. 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.V270458.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following 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 DS0000021774.V270458.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 789 Plans of care were of a good standard. Work on attendance at reviews was in process. Risk assessments were in place. Resident’s health needs were met. There were a number of errors in the administration of medication. Controlled drugs were appropriately kept and recorded, and trained staff administered medication. EVIDENCE: Plans of care were of a good standard. Consultation with relatives on attending reviews had been put in place, although not all relatives had responded. To protect residents, risk assessments for falls and other risks were in place. 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. Nutritional screening was undertaken for all residents, with food and fluid intake records in place. Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 Page 11 Medication records were checked for three residents. There were a number of administration errors, including signatures for medication, which had not been administered, and some medication which had been administered but not signed for. Aspirin had not been signed for on a MAR sheet, and one medication for a resident had run out. Controlled drugs were appropriately kept and the administration properly recorded. Trained nurses administered all medication. A pharmacist advised staff at the home. Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 Residents chose how to spend their day. There was a suitable range of activities provided. The activities co-ordinator required more staff support. Work was taking place in order to provide more individualised activities for residents. Relatives and friends were welcomed to the home and the home had links with the local community. A well balanced diet was provided which included special diets and residents choices. There were insufficient staff to help residents who required feeding. 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. On the day of the inspection, the activities co-ordinator was working on her own with ten service users and no other staff were present for a period of time. This did not provide the support, which the residents needed. The home also had a multi-sensory room and activities room. Trips took place for residents who were able to take part in them. Questionnaires had been sent to relatives to gain information on resident’s interests and hobbies prior to admission to the home so that more individualised activities could be provided for them. This work was in the process of completion. Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 Page 13 Relatives and friends were welcomed to the home and could visit at any time. The home had links with the local community, including a local school, and churches. Residents were encouraged to go out as much as possible and staff accompanied them shopping and going to the local pub. 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. There were a high number of residents who needed help with eating, and staff interviewed said that there were still not always sufficient staff to help them. The cook was aware of special diets. Drinks were served regularly throughout the day. Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 Page 14 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 18 The home had a complaints procedure which met the standards. One complaint had been received during the previous twelve months. Residents were protected from abuse by the homes policies and procedures. 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. Relatives spoken to said they knew how to complain if necessary but had no complaints at present. Staff were aware of the complaints procedure. There had been one complaint at the home during the previous twelve months. The home had policies and procedures on adult protection. 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 DS0000021774.V270458.R01.S.doc Version 5.0 Page 15 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 The home’s environment was generally of a good standard. The building complied with the requirements of the fire service and environmental health department. Some areas required redecoration, and some carpets were stained. The outside area of the home was safe and accessible to residents. EVIDENCE: All areas of the home were clean, fresh smelling and generally well maintained. Furnishings and furniture were of a good standard, although some damaged chairs had not yet been replaced. Some decoration of corridors and a dining area had taken place, however, some dining areas, doors, skirting boards and doorframes still required redecoration. Some resident’s bedrooms required redecoration. Carpets were stained in some areas including resident’s bedrooms and lounges. There was a maintenance and renewal programme in place. The outside garden area was enclosed, well maintained and accessible to residents. The building complied with the requirements of the fire service and environmental health department. Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 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 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 29 30 Staffing rotas showed that the agreed staffing levels were maintained. However, staff felt that there were insufficient staff to meet the residents needs. Recruitment files contained all of the required information, and CRB and POVA checks were carried out on all staff. Training for staff was ongoing and comprehensive. 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 members felt that there was still insufficient staff to help residents at mealtimes, and also felt that the high dependency levels and challenging behaviour of residents required more staff on duty. There was an appropriate gender and skill mix. 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. The majority of staff had received specialised training on dealing with dementia. Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 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 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): 35 36 38 Systems were in place to ensure that resident’s finances were protected. Staff supervision took place, but was not always at the required level and was not recorded appropriately. A new system was being introduced to address this. There was a health and safety policy in place. Staff training was ongoing. EVIDENCE: There were no residents who were able to control their own finances, because of their mental condition. The majority of resident’s finances were looked after by their relatives. The home’s administrator was appointee to ten residents and the DSS was aware of this. Written records of all transactions were maintained, and secure facilities were provided for the safe keeping of money and valuables. For the safety of residents, the home’s accounts were regularly audited. Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 Page 18 Supervision helped staff to do their job, by including aspects of practice, philosophy of care and career development needs. It did not however, always take place at the required level, and was not recorded appropriately. There was a new system of supervision in process of implementation which when complete would ensure adequate recording. Practical daily supervision of staff was 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 received training in health and safety, moving and handling, fire safety, first aid, and infection control. 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 DS0000021774.V270458.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x x STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 2 x 3 Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 Page 20 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. 2. 3. 4. Standard OP9 OP9 OP9 OP12 Regulation 13 13 13 12 18 Requirement All medication administration must be accurately recorded. Resident’s medication must not be allowed to run out. Aspirin and other ‘homely remedies must be accurately recorded on the MAR sheet. There must be sufficient staff on duty to assist the activities coordinator when a number of residents are taking part in activities. The damaged chair must be repaired or replaced. The chairs with damaged arms must be repaired or replaced. (Timescale of 01/09/05 not met). All stained carpets must be cleaned or replaced. All residents bedrooms must be maintained in good decorative condition. The identified doorframes, doors, and skirting boards must be redecorated. The two dining areas must be redecorated. (Timescale of 01/09/05 not met). There must be sufficient staff DS0000021774.V270458.R01.S.doc Timescale for action 08/11/05 08/11/05 08/11/05 08/11/05 5. OP19 16 01/02/06 6. 7. 8. OP19 OP19 OP19 23 23 23 01/02/06 01/02/06 01/02/06 9. OP15OP27 12 18 01/01/06 Page 21 Chatsworth Grange Nursing Home Version 5.0 10. OP27 12 18 11. OP36 18 employed at the home to help residents appropriately at all mealtimes. (Timescale of 01/08/05 not met). An assessment of resident’s levels of dependency must take place, and sufficient staff must be employed to fully meet all residents’ needs. All formal supervisions must be recorded. (Timescale of 01/09/05 not met). 01/01/06 01/01/06 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. Refer to Standard OP12 OP30 Good Practice Recommendations 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 DS0000021774.V270458.R01.S.doc Version 5.0 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Chatsworth Grange Nursing Home DS0000021774.V270458.R01.S.doc Version 5.0 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. 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