Inspection on 20/04/05 for Danesford Grange Care Home

This inspection was carried out on 20th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Danesford Grange Care Home 30/06/08

Danesford Grange Care Home 27/07/07

Danesford Grange Care Home 06/07/06

Danesford Grange Care Home 28/10/05

Danesford Grange Care Home 22/03/05

Danesford Grange Care Home 17/08/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Danesford Grange Nursing & Residential Home Kidderminster Road Bridgnorth Shropshire WV15 6BW Lead Inspector Joy Hoelzel Unannounced 20 April 2005 10:00 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. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Danesford Grange Nursing & Residential Home Address Kidderminster Road, Bridgnorth, Shropshire, WV15 6BW 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) 01746 763118 01746 767551 Mr Michael Blandy, Mrs Gwendoline Blandy Mrs Joan Thomas-Brough Care Home 32 Category(ies) of 32 Old Age registration, with number of places Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Mrs Thomas –Brough must remain supernumery in her role until a deputy manager has been successfully recruited and has completed a full induction. thereon after, the registered manager be rostered as supernumery for a minimum of 25 hours per week. Further evidence of knowledge of adult protection procedures for all staff members must be available within the next 6 months.(March 2004) Evidence of Mrs.Thomas – Brough’s responsibility for budget planning and management especially with regard to staffing, equipment and activities for service users, must be available to inspectors by the next announced inspection. Systems to ensure formal supervision is in place between the manager and proprietor at least six times a year. Date of last inspection 22/03/05 Brief Description of the Service: Danesford Grange is registered with the Commission for Social Care Inspection to provide accommodation, personal and some nursing care for a maximum of 32 individuals. It is located on the outskirts of Bridgnorth, on the main road to Kidderminster. The property consists of an older building and an extension, which has been added in recent years. It is set back from the road in its own grounds. Countryside views can be enjoyed from most elevations of the property. The accommodation is laid out over four levels each being named after trees and accessed by a passenger lift. The home has both single and double bedrooms, some of which have en suite facilities provided. The home is independently owned by Mr and Mrs Blandy who play an active part in the home’s management.Ms Joan Thomas-Brough RN, who has been in post since 07.04.03, manages it on a day-to-day basis. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 5 hours on Wednesday 20th April 2005. This was in response to a vulnerable adults protection referral of an allegation of misconduct of a member of staff and an incident of medication mismanagement. The vulnerable adult protection meeting was held at the home later in the afternoon of the day of the inspection. A tour of the premises took place, care records, staff personnel file and relating documents were inspected. Discussions were held with the owner, senior management, care staff, service users and relatives. The requirements made following the unannounced inspection on 22nd March 2005 have not been inspected for compliance at this inspection. There were delays in the home receiving the draft copy of the report. The requirements will therefore be carried forward, together with any requirements from this inspection and will be checked for compliance at a later date. What the service does well: What has improved since the last inspection? A deputy matron has recently been recruited and although she is ‘settling’ into the new role, has recently found it difficult as the manager had been off sick and she was unsure of the role of the manager. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 6 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. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 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 Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 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) 3,6 The admission procedure continues to ensure that prospective service users move into the home being assured that the care needs will be met. EVIDENCE: The care plans include a copy of the pre admission assessment undertaken by a senior member of staff. A care plan is then generated from this information at the point of admission. Senior staff commented that if at all possible the prospective service users visits the home prior to making a decision to move in, however this is not always possible and at times relatives/representatives visit. The home does not provide an intermediate care service. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 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) 7,8,9,10 Systems and arrangements must be in place for ensuring that all health, social and personal care needs are identified and met. A complete review is required for medication administration. The deficits in these areas have a potential for placing service users at risk. EVIDENCE: Each service user has a plan of care that is generated from the pre admission assessments; the plan is reviewed at least monthly or more frequently as care needs change. The plan does not evidence the involvement of the service users or relative/representative in drawing up the plan or subsequent reviews. Service users spoken with commented that they are aware of the staff having access to the care plan but they did not have any involvement in it or indeed were asked their opinion. The plan must include all aspects of the health, social and personal care needs of the individual. One care plan inspected did not include a specific plan for the treatment of a pressure ulcer although the staff had been treating this. The care plan evidences that health care needs are met with the relevant health care agencies being involved when needed. One service user was at Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 10 particular risk of falling due to poor mobility, the care plan evidences the involvement of the physiotherapist and the subsequent provision of a walking frame to reduce the risk of harm. The Commission for Social Care Inspection had been notified of an error in the administration of medication namely night time medication. The service user was not harmed following this incident, information and advice was sought immediately from the general practitioner and the service user was later visited by the G.P. A revised system of the administration of medication had been implemented by the deputy matron, with new recording books and equipment being available to staff. The system of medication storage and administration was not fully assessed on this occasion. The Commission for Social Care Inspection pharmacist inspector will be requested to visit the home to fully inspect this area. Staff were observed to be knocking on bedrooms doors before entering and placed on each door is an instruction notice to ‘stop, knock and wait’. A requirement following the vulnerable adult investigation is that all staff must be instructed during the induction programme on how to treat service users with respect at all times. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 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) 12,13, Whilst activities are provided within the home there is little evidence of consultation with service users regarding their preferences, and is dictated to a large degree on the time constraints of the care staff on duty. EVIDENCE: The home does not employ a social activities organiser, although the manager informs that discussions are being held as to the possibility of recruiting a person. Social and recreational activities are arranged by staff at the home, entertainers visit the home every two months, exercise classes are held weekly and trips to local places of interest are arranged. Service users must be given the opportunity to discuss their preferences with up to date information circulated in an appropriate format. Service users commented that they felt that the activities organised were sufficient and suitable, one lady stated that she preferred to watch her television or read. Visitors to the home stated that they could visit at times suitable to their relative and were always welcomed by the staff. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 12 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) 18 The vulnerable adults procedure was correctly instigated when an allegation was made. Senior staffs are aware of the procedure and have received training. EVIDENCE: The responsible individual of the home referred an incident alleging physical abuse and inappropriate behaviour by a member of staff to the vulnerable adults multidisciplinary team. The member of staff was suspended from duty while the investigations were taking place. This was fully investigated and the following requirements were made 1. The member of staff to be re instated on the following conditions 1.a. The full induction programme to be undertaken with concise records kept 1.b The member of staff is not to work unsupervised until full competency is achieved. 1.c A senior member of the care team is to be allocated as a mentor. 1 d. The care staff must receive weekly formal supervision sessions with the line manager and records kept. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 13 2. The induction programme must be to specifications of ‘skills in care’ formerly ‘topps’ 3. A follow up meeting to be arranged In June 2005. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 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) 19,21,24,26 The continued use of wedges for keeping doors open has the potential for placing all service users at great risk. Lack of facilities are placing staff and service users at risk and undermining privacy and dignity issues. EVIDENCE: The home offers single and double accommodation to 32 older people. Service users spoken with commented that they are very happy living at the home, one service users was very pleased with her room as she has a lovely view over the back garden. The home must ensure that the requirements of the local fire service are complied with. It was observed that wedges are used to prop open doors. If it is inconvenient for doors to be remain closed, then a ‘swing free’ self closer should be fitted to the doors and wired into the fire alarm system, so as to close when the alarm is triggered. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 15 Service users must have the choice of having their bedroom doors open whenever they wish but their safety must not be compromised with the use of wedges. Staff commented that they have raised money through fund raising activities for the purchase of a walk in shower for use by service users. An appropriate place for the installation has still to be agreed. This facility will enhance the choice of bathing facilities available for service users. The agreement of the offer of a lockable facility on service users private rooms has been included in the care plan. However the care plans inspected did not evidence that this had been discussed with the service user. The door locking facility must be available on all private bedrooms so as to offer a true choice to each service user of having their door locked or not. This must be their decision and not the personal viewpoint of the responsible individual. The installation of sluicing disinfectors, as required following the previous inspection, for the safe disposal of bodily waste, will enhance the working conditions for staff and reduce the risk of contamination, splash back accidents and cross infection. All areas where personal care is undertaken by staff are provided with hand washing facilities Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 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) 27,29,30 Care staff were working positively with service users to improve their quality of life. However senior staff morale was low, with high levels of sickness resulting in a disruption of clear leadership. EVIDENCE: The duty rota and staff confirm that staffing levels remain at minimum levels. The staffing numbers and skill mix must be determined by the dependency needs of service users, as dependency needs fluctuate so the staffing levels must be flexible to these changes. Staff commented that additional staff would assist and enhance the personal and social care provision for the current service users. The senior staff stated that National Vocational Training at levels 2 & 3 are continuing. Care staff commented that they were enjoying the training. Staff personnel files indicated that all the required checks are carried out, new staff must not commence working at the home until a Criminal Record Bureau disclosure has been received. The induction programme for all new starters must be reviewed and in line with the skills in care (formerly TOPPS) specifications. All staff must receive the induction training within the first 6 weeks of their employment and foundation training within the first 6 months. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 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) 31,32,38 The leadership skills do not give clarity and direction to the staff, the roles and lines of responsibility are not clearly defined and there appears to be a dependence on the care staff to deliver an acceptable service. EVIDENCE: The registered manager is a first level nurse and is currently working towards the registered managers award. It was obvious during the course of the inspection that difficulties are still present with the management structure, the delegation of responsibilities and the health of senior staff. The manager and deputy were both at the home and both were supernumery for the day due to the recent concerns of the mismanagement of medication and the vulnerable adult investigation. The manager had just returned from sick leave and was clearly far from well, she was ‘very stressed and finding it difficult to cope’. The deputy manager Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 18 had been filling the role of manager in her absence. The deputy manager stated that she was not familiar with this role and had found it challenging. The deputy manager must be commended on implementing a revised safe system of medication administration when the error had been detected. Both manager and deputy were endeavouring to support each other but were ‘struggling’ to assume and adopt a clear sense of direction and structured leadership approach. There appears to be confusion as to the roles and responsibilities of each of the staff groups, with a dependence and reliability on the senior care staff. Extra support, guidance and leadership is required for the senior staff to ensure a positive approach to service delivery is developed. Care staff commented that they could approach the senior staff if needed and were observed to be communicating well together. One service user had not been introduced to the responsible individual although she has lived at the home since May 2004. The health and safety of service users and staff are being compromised by the use of door wedges. Hot water temperature is being monitored on a weekly basis and is in line with the required levels. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 1 x 3 x x 1 x 1 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x 1 x x x x x 2 Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 20 yes Are there any outstanding requirements from the last inspection? 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 7 Regulation 15(1) Requirement The service users care plan must be drawn up with the involvement of the service user, recorded in a style accessible to the service user, agreed and signed by the service users whenever possible and/or representative. The care plan must specify the preventions, treatments and interventions needed for service users who have developed, or at risk of developing pressure ulcers. The registered person must ensure that arrangements are in place for the safe recording, handling, safe keeping, safe administration and disposal of medicines received into the home All staff must be instructed during the induction period on how to treat service users with respect at all times. Service users must be given the opportunity to discuss their social, recreational and leisuretime preferences with up to date information circulated in an appropriate format. Timescale for action 31st July 2005 2. 8 12(1),13( 1) Immediate 3. 9 13(2) Immediate 4. 10 18(1)( c) Immediate 5. 12 16(2)(m)( n) 31st July 2005 Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 21 6. 7. 19 24 23(4)(a)( b)(c)(d)(e ) 12(4) 8. 9. 24 26 10. 27 11. 29 12. 30 13. 32 Door wedges must not be used to prop open doors to communal or private areas of the home. Doors to service users private accommodation must be fitted with locks suited to service users capabilities and accessible to staff in emergencies 12(4),13( Service users are provided with 4)(a)(b)(c keys unless their risk ) assessment suggests otherwise 13(3),16( Sluicing disinfectors are 2)(j) required in areas of the home where there is a need to dispose of bodily waste. 18(1) The staffing numbers and skill mix must be determined by the dependency needs of service users, as dependency needs fluctuate so the staffing levels must be flexible to these changes. 17 New staff must not commence working at the home until a Criminal Record Bureau disclosure has been received. 12(1),18( All staff must receive the 1)(a)(c) induction training within the first 6 weeks of their employment and foundation training within the first 6 months. 10(1),12( The registered manager must 1)(2)(3)(4 ensure that the management )(5) approach of the home creates an open, positive and inclusive atmosphere Immediate 31st october 2005 31st October 2005 31st October 2005 Immediate Immediate Immediate 31st July 2005 14. 15. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 22 Danesford Grange Nursing & Residential Home 1. 2. Standard 13 It is recommended that a suitable person is recruited for developing and arranging social, leisure and recreational activities based on service choices and preferences. Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 2nd Floor St Davids Court Union Street Wolverhampton WV1 3JE 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 Danesford Grange Nursing & Residential Home E56 000022250 Danesford Grange Nursing & Residential Home V222609 UI 200405 Stage 4.doc Version 1.30 Page 24 - 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!