Inspection on 27/07/07 for Danesford Grange Care Home

This inspection was carried out on 27th July 2007.

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

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

Other inspections for this house

Danesford Grange Care Home 30/06/08

Danesford Grange Care Home 06/07/06

Danesford Grange Care Home 28/10/05

Danesford Grange Care Home 20/04/05

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 Care Home Kidderminster Road Bridgnorth Shropshire WV15 6QD Lead Inspector Janet Adams Key Unannounced Inspection 27th July 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Danesford Grange Care Home DS0000022250.V340250.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. Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Danesford Grange Care Home Address Kidderminster Road Bridgnorth Shropshire WV15 6QD 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) 01746 763118 01746 767551 danesfordgrange@ukonline.co.uk Mr Michael Blandy Mrs Gwendoline Blandy Miss Joan Thomas Care Home 33 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (33) of places Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Maximum number of beds can only be thirty three (33) of which three (3) beds may be for dementia care. 16th January 2007. Date of last inspection Brief Description of the Service: Danesford Grange is a care home providing accommodation, personal and nursing care for thirty three older people, of whom three may have dementia related illness. It is privately owned and located on the outskirts of Bridgnorth, on the main road to Kidderminster, and can be accessed via a local bus route. 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 management team makes the services of Danesford Grange known to prospective residents in their statement of purpose, and its brochure/service user guide. A copy of the most recent CSCI (The Commission for Social Care Inspection) Inspection report was also seen to be freely available at the entrance of the home for people to look at. The current fees charged vary between £ 319 and £619 per week depending on the care, support and accommodation provided. Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried this inspection visit to the home. The inspection lasted a total of 9 hours over a period of two separate visits. A few weeks before the inspection was carried out, CSCI (The Commission for Social Care Inspection.) wrote to the home manager to request some necessary information to assist with the inspection. This meant that although Danesford Grange knew the inspection was imminent, they were not aware of any date or time. On the afternoon before the inspection, two hours were spent observing the care being given to a small group of people in one of the main communal lounges. The care of four people was looked at in depth when comparisons with the observations were made with the home’s records and the knowledge of the care staff. Other inspection information was also gathered in a variety of ways. It included observing activity within other parts of the home, inspecting the premises, an ‘in depth look’ at records for staff, observing, talking and listening to over half of the 33 people living there, and the staff on duty at the times of the inspection. Four residents completed written comments on this occasion. Many others were happy to share valid comments when they were spoken to in private or together in groups in the lounges. Five visitors were available to talk to on this occasion, and three relatives sent back comment cards to CSCI. All made positive comments about the home, and these are included in the main body of the report. Everyone, including residents and staff were very welcoming and helpful throughout. A total of 29 out of a possible 38 National Minimum Standards for Older People were assessed on this occasion. What the service does well: The people living at Danesford Grange are provided with a comfortable, clean environment in which to live. The home offers good nursing care to frail older people. Visitors and people living at the home commented positively on the attitude and competencies of all levels of staff. One relative who visits the home on a regular basis stated, Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 6 ‘The home provides an excellent standard of care.’ Everyone who lived and visited the home commented that the meals provided at Danesford Grange very good. One person in particular commented there was a good availability of snacks in between meals if people wanted them. What has improved since the last inspection? What they could do better: As a result of this inspection five statutory requirements and three recommendations were made. Although the home has a statement of purpose and service user guide they are not up to date with information about funding/payment arrangements and fee rates. Prospective service users need full information before making a choice to live at a home. The home needs to improve the systems for care plan records to ensure the Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 7 paper copies held on file contain all the relevant updates and changes logged on the computer system for staff to refer to ensure people to get the care they need and prefer in a safe manner. Lack of locks to bedroom doors do not offer people living at the home the privacy they may prefer. Management of some aspects of health and safety in the home is not in line with necessary legislation. Infection control, accident and chemical management systems need further development to show the home maximises the safety of people living at the home in line with necessary legislation. Safe working systems for bedrail use in the home must be developed in order to show effective remedial actions are carried out to maximise resident health and safety at all times. 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. Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 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 Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 &3 Quality in this outcome area is good. Prospective residents and their representatives are provided with most of the information needed for them to choose a home, which will meet their needs. Individuals have their needs fully assessed before they move into Danesford Grange to make sure that the facilities, staffing and specialist services available meet the ethnicity and diversity needs of the person. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Upon arrival to the home reception area, visitors are welcomed by a variety of information about the services Danesford Grange provides. This especially makes a good start for any new visitors to the home. Examination of the home’s Statement of Purpose and Service User Guide which had been updated in June this year confirmed that the home continues Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 10 to have clear, user friendly information for people to access before they move in. However, review of its contents shows it does not quite fully comply with the change in The Care Homes Regulations of September 2006, and needs more detail concerning fees and funding arrangements. The above information is included in the ‘Welcome Pack’ issued to every new person who moves into the home. The welcome pack is personalised with the individuals name so they know the information has been especially put together to meet their needs. It is colour coordinated to make it easier to read and understand. Evidence seen in paperwork for three residents admitted since the last inspection shows a wealth of information gets gathered by the home team from a variety of sources, including the local authority social work team, health professionals including hospital staff, and community nursing teams where necessary, to make sure the home can fully meet any prospective residents’ needs. The details written down also confirm that the assessments are conducted professionally and sensitively and have involved the resident, as well as family members or representatives of the person, as deemed necessary. Examination of people’s terms and conditions of living at the home showed they were of variable quality. It is positive the records of someone paying for his own care had a clear breakdown of who pays what amount, and the person responsible for paying the fees had signed this. However, this information seen in records of people whose care was funded by a placing authority did not have this detail. The home management are to be commended how they managed the admission of a person who arrived at the home unexpected in an emergency situation via a local hospital. Danesford Grange was completely unaware of the plans for this persons admission. Fortunately the home was able to accommodate her and she was overheard talking to other residents saying how pleased she was to have arrived in such a nice place. Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 11 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): 7,8, & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all service users’ social care needs and risk assessments are set out in their individual plans of care. This does not ensure that all care needs have been addressed and will be fully met. Staff are sensitive to the individual needs of each service user and meet these in a professional manner. EVIDENCE: All written comments received about the care the staff team carries out for its residents were very complimentary. One person wrote to CSCI to say, ‘ The care here is A1’ Some people were seen to be so frail they were not able to communicate their Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 12 opinions, therefore the two hours spent observing people in the communal lounge the day before the main inspection day was helpful in confirming findings of the inspection process. Staff were seen to be attending the needs of residents in a respectful manner and were very knowledgeable about the individual needs and preferences of the people they were caring for. A conversation overheard by two new residents praised the staff for their caring attitude. The installation of locks to communal toilets and bathrooms has improved the opportunity for team people to maximise their privacy when using these facilities. The Registered Manager confirmed that the care planning system is now all computerised with a suitable security back up system. Although she expressed satisfaction with this new system she did recognise they were still experiencing teething troubles with it. Due to the nature of this system the paper copies of care records held in the filing cabinet drawers of the office are not up to date. However she did explain that if a resident wished to look at their care plan, it would be printed off for them to see it. The manager also stated that relatives are welcomed into the office to join in care reviews on line. Access to this office is not good as people have a high step to negotiate to gain access. The computer screen itself is quite small and does not enhance the opportunity of a second person looking at the information. On the day of the inspection the computer system was reported to be slow and therefore the process of retrieving important up to date information about people living at the home was very time consuming. This must have a negative impact on the care team who wish to review and check out care details in normal working times during a busy shift when this happens. Care records of four people who live at the home were looked at in depth. All paper records looked at were dated October 2006, and were therefore out of date. This means in the event of computer failure the home team do not have up to date information available about the people living at the home. This does not safeguard these individuals. The above issues were discussed with the home manager during the inspection. Analysis of care plans also confirmed that some care plan information was very well written and gave a clear picture of the needs of the people concerned. However, this was not of the same standard in the records of other people living at Danesford Grange. As identified at the key inspection in July 2006, some risk assessments and screening tools had not been fully completed for everyone’s plan of care. For example, important wound assessment and evaluation information of a Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 13 person who had recently moved into the home was not recorded in the plan of care to manage the person’s sore heel. In October 2006 a person living at the home had an accident as a result of being entrapped in bedrails. The risk assessment on the computer system as well as on paper had not been updated since September 2006, meaning that there was no information regarding this accident in the plan for the safe use of bed rails for the person. Since a random CSCI inspection in January 2007, there have been major improvements in the medication management systems within the home. A new medication storage room has been constructed and all medications were seen to be stored securely. The review of the receipt, administration and disposal of medication for two people spot-checked were also satisfactory. In the time between the January 2007 inspection and this key inspection, the home has also received a specialist inspection from the CSCI Pharmacy Inspector. The home has not yet received this report. Danesford Grange Care Home DS0000022250.V340250.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): 12,13,14 & 15. Quality in this outcome area is good. The daily life and social activities arranged for service users takes into account the differing expectations, preferences, lifestyle and capacities of each individual. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Positive inspection findings confirmed the home consistently provides a range of stimulating activities and leisure opportunities for the people living at Danesford Grange. The home publicises the communal activities it plans in a variety of ways including the use of colourful posters throughout the home. Information provided by the home management prior to the inspection confirmed the activities programme has been further enhanced by the introduction of regular visits from hand and body masseurs especially trained to treat people who are very frail. Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 15 One person wrote to CSCI to say Being able to get out more has definitely improved life at the home’. Two people who live at the home also confirmed they enjoyed their visit to a local pub for a meal the night before inspection. Discussion with relatives met during the inspection confirmed the home had an open welcoming visiting hours policy, which encouraged family involvement in line with the wishes of the people living at Danesford Grange. Relatives also volunteer to help with the weekly bingo sessions. The information provided to CSCI confirmed religious needs of the people currently living at the home were met by the regular visits of the local vicar. Several people who live at the home are not fully able to answer questions and write down their opinions about Danesford Grange due to their medical related conditions and being so frail. Therefore the inspector spent time in the main communal lounge to observe of the behaviours of these individuals in response to the care and support they were given. They were observed for a two-hour period which included a lunchtime. It is positive that staff spent quality time with the residents during this period, establishing a sociable rapport with residents in a positive knowledgeable and caring manner. Residents were cared for with respect, and were offered support in an unhurried relaxed atmosphere. Two people who are highly reliant on the staff for their well-being were supported to keep as independent as they could. A lady with challenges to her vision was prompted and encouraged about her meal and how it was laid out on the tray so she could make a start to feed herself. Restaurant style menus seen on tables in the dining rooms were up to date with the meal choices of the day. On the second inspection day many residents were seen thoroughly enjoying a regular treat of fish and chips from the local chip shop. All comments received by people living at the home and their relatives was positive – five wrote to state The food is good’, others commented They give me snacks if I ask for them and The food feeds me well’ Danesford Grange Care Home DS0000022250.V340250.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): 16 &18 Quality in this outcome area is adequate. Danesford Grange has a complaints procedure, which is accessible so that people who use the service have information of how to make complaints about the home. Training is provided so that people are protected from abuse and have their legal rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is included in the statement of purpose and resident ‘Welcome Pack’; a copy is also displayed on the notice board at the entrance to the home. No complaints have been sent directly to Commission for Social Care Inspection since the inspection in October 2005. Examination of the complaint logbook for the home described four issues, which were dealt with in a professional manner within the 28 day timescale necessary. Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 17 A copy of the local multidisciplinary procedures for Shropshire is available, as are the homes own policies and procedures for dealing with adult protection issues. Abuse awareness is included in the induction programme for all employees and further training is being arranged in this area to keep the care team updated every two years. The home provided CSCI with a wealth of information how they have improved to welcome complaints and to raise people’s awareness how to safeguard vulnerable individuals living in the home. For example; The results of the Danesford Grange Quality Audit 2007 confirmed that 50 of residents felt they were kept safe and well protected ‘all of the time’, and the other 50 stated this to be ‘most of the time’ However, review of systems to manage some aspects of health and safety in the home as well as the safekeeping of the monies and valuables of people living at the home confirm they are no longer as robust as they used to be. This means the well being of people living at Danesford Grange is currently not fully safeguarded. This matter is reported in more depth in the last section of this report entitled ‘Management and Administration.’ Danesford Grange Care Home DS0000022250.V340250.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): 19,20,21,22,23,24,25,& 26. Quality in this outcome area is good. The physical design and layout of the home continues to improve to enable service users to live in a safer, better-maintained and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well lit, clean and tidy and smells fresh. All comments received from the people living at the home and their relatives expressed the appreciation of the results of the ongoing programme of refurbishment and redecoration. Work has been carried out internally as well as externally resulting in the home generally being more welcoming, safe and comfortable. Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 19 The home have improved their arrangements for fire safety and have an appointment with the local fire officer in the near future to confirm all aspects of this project meet necessary standards. People visiting and living at the home were especially positive about the new furniture, carpets, and redecoration of their bedrooms. All residents who wrote to CSCI commented the gardens had greatly improved in the past six months and they now enjoyed improved views of the garden since it was extensively landscaped. Tree cropping has also resulted in improving the natural lighting to bedrooms and lounges. Staff also expressed their appreciation of the purchase of new equipment, which has made their responsibilities easier and safer. Over half of the bedrooms were looked at during the tour of the home. A lady who was recently admitted to the home in an emergency situation stated her room, ‘Is lovely – the curtains are beautiful.’ All bedrooms were appropriately personalised, furnished and equipped to meet resident’s needs. Three people who live at the home and two visiting relatives spoken to all confirmed they were happy with the standard of bedroom accommodation although some were not aware they could have locks for them. Although the manager stated that some bedroom doors had locks installed, this has been an issue which is not yet fully resolved. As recorded earlier in this report CSCI recognise locks are now installed in all communal bathrooms and toilets. The loud volume of the nurse call system as described in the previous inspection report has not as yet been addressed. The home has a handyman who follows a programme of routine works and keeps appropriate records to show the day-to-day maintenance of Danesford Grange is of a satisfactory standard. During the inspection tour of the home, a bedroom window, which was seen to have a cracked pane of glass at floor level, was actioned immediately. Random hot water testing in areas accessible to residents and visitors was ‘spot checked’ in two bathrooms and was found to be satisfactory. Although the majority of the home was seen to be spotlessly clean, inspection of working conditions in high risk areas such as the sluice and the laundry currently challenge infection control standards. Hand washing facilities, as well as systems for the cleanliness and storage of equipment, and clinical waste disposal all need to be improved. It is recommended the management revisits a recent infection control audit carried out at the home by the Health Protection Agency in order to measure and monitor current shortfalls so that they are improved in line with current good practice. Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 20 When these issues were discussed, it was positive to be told by a management team member that the staff team are currently being retrained in infection control practice. Likewise it was good to be informed by the manager that alternative arrangements how the external clinical waste storage area were being explored to make it more hygienic as well as cost effective. Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 21 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): 27,28,29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are generally supported and protected by the homes recruitment policy and practices. Staff in the home are being trained and are in sufficient numbers to fulfil the aims of the home and meet the changing needs of the people currently living at Danesford Grange. EVIDENCE: All comments the people who live at and visit Danesford Grange made about the staff team were very positive. A lot of similar comments such as, ‘Staff are very good, they look after me well,’ were received as part of the inspection process. It was positive to overhear two residents who were having a conversation also be full of praise for the efforts of the staff team. It is positive to report that staff retention has improved at the home and care is now carried out for the people living there by a consistent workforce. Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 22 At least one registered nurse is on the premises over the twenty four hour period, supported by care and ancillary staff. Positive observations of care being carried out on both inspection days reflected a comment made by relative who commented, ‘Staff morale has got better, they are now a good team’. 73 of the care team have attained their necessary NVQ qualification. Five staff personnel files were selected for inspection each contained references, identity checks and criminal record bureau disclosures, with the exception of one file for a new recruit, where it was seen that a verbal reference had been accepted in place of a second written reference. This issue was discussed with a management team member during the inspection. Training and development undertaken are recorded on a training matrix with copies of any certificates received kept in the personnel file. This was fully reviewed in July 2007and the details recorded fully matched the content of staff files checked. The induction evidence seen on staff files confirms this to be a very thorough process overseen by the home administrator. The last two new carers were also sent on a registered Skills for Care training programme. It is positive to see that at the end of their induction staff complete a questionnaire to check they feel prepared to do their job. Comments seen included, I was pleased with what I had learnt I felt home was very clean and staff well organised.’ The files were also seen to contain excellent evidence of fire and health and safety training the staff team had undertaken. . Danesford Grange Care Home DS0000022250.V340250.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): 31,33,35 & 38. Quality in this outcome area is adequate. Experienced, suitably qualified individuals ensure management arrangements are meeting the majority of the needs of the service. Some systems for the health, safety and welfare for residents, staff and visitors need to be improved and adjusted to make sure that they are kept up to date, to meet people’s changing needs as well as necessary legislation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 24 At the start of the inspection the Registered Manager was complimented for the good standard of information sent to CSCI in preparation for this inspection. The information clearly confirmed the efforts made by the home team to show how it is is being run in the best interests of the people living at Danesford Grange. It is positive to be informed that recent and future improvements take into account the opinions and needs of people living at the home.The forthcoming plans for better wheelchair access to the gardens is currently in the process of been actioned following a successful grant application for this purpose from local authority. It is obvious the management team at the home have worked hard to improve the quality of the living and working conditions in the home.Team involvement continues with regular monthly meetings with the residents and staff team. Satisfaction questionnaires are sent out periodically to people living at the home, relatives and staff.Some of the feedback from the home’s ‘2007 Annual Quality Audit’ was useful when compared with CSCI findings. However, some of the changes in systems within the home need to be further developed in order to fully comply with National Minimum Standards for care Homes for Older People. Now that the system for the recording the safekeeping of service users monies and valuables is computerised, it is no longer robust. It has not been set up so that the two staff members who check the monies held in safekeeping for people living at the home can actually record their names, like they could when the ‘paper system’ was in use. When two staff members were observed checking some cash out for a resident, it was seen that the home was also holding a watch and bracelet in safekeeping for the person, however the computer printout accounting for valuables for that person made no reference to the bracelet. Discussion with the Registered Manager confirmed that the valuables kept in the safe which belong to the people who live at the home not yet been logged onto the computer system, and paper records had not been kept up to date. This means the home does not have an accurate record of the valuables kept in the safe. This does not safeguard to property of the people who live at the home. Safe working systems in the home require further development so the home management can demonstrate everyone is being cared for safely. The home accident book was not maintained in line with Health and Safety legislation, and confidentiality systems expected to be maintained as per the Data Protection Act are not followed fully. Accident management systems for the home does not have a follow up procedure to confirm all accidents are investigated and care plans are Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 25 updated to make sure the risk of them happening again is kept to a minimum.In October 2006 the accident book described an incident when someone had their legs trapped in bedrails. Recordkeeping for the person confirmed that the bedrails had not been checked until two days later. In addition, records of audits of bedrails showed that the month when the accident happened no bedrail checks had been carried out. It is also a concern that the person delegated to carry out this responsibility had no evidence of competency for this role in her training and supervision files. Spot checks of the home policy and procedures file showed there is ‘good practice based evidence guidance’ for staff to follow. However, this does not always happen.Earlier in the report the case of the person requiring wound care was described ,and information seen in the person’s records about this matter was not in line with expected nursing practice, or the home’s procedure. Whilst carrying out a tour of the home, unlabelled containers of chemicals were seen on the cleaner’s trolley, and other chemical containers seen around the home had handwritten labels insitu. This does not meet COSHH (Control of Substances hazardous to Health) legislation. Records for the regular monitoring of equipment e.g. fire safety, water temperatures, emergency lighting, portable appliance tests were all up to date. Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 26 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 2 3 2 STAFFING Standard No Score 27 3 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 27 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 OP1 Standard Regulation 5a Requirement Information made available for people thinking about moving into Danesford Grange needs further details in order to fully comply with recent care home legislation of September 2006 regarding fees. Care plan systems need to be developed to make sure there is up to date robust recordkeeping available at all times for staff to refer to ensure people to get the care they need and prefer in a safe manner. Doors to service users private accommodation must be fitted with locks suited to service users capabilities and accessible to staff in emergencies. Previous timescales of 30/11/05, 16/01/07, and 31/03/07 not met. Accident management systems in the home must show effective remedial actions are carried out and documented in care records to maximise resident safety and DS0000022250.V340250.R01.S.doc Timescale for action 18/10/07 2 OP7 Schedule 3 1(b) 18/11/07 3 OP24 12(4) 18/11/07 4 OP38 13 (4) (c) 18/09/07 Danesford Grange Care Home Version 5.2 Page 28 minimise the risk of accidents happening again. 5 OP38 13 (6) Safe working systems for bedrail 18/09/07 use in the home must be developed in order to show effective remedial actions are carried out to maximise resident health and safety at all times. The health and safety systems 18/09/07 for managing chemicals at Danesford Grange need to be improved in line with necessary legislation to make sure all people living working and visiting the home are kept safe. 6 OP38 13 (4) (c) 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. OP2 Refer to Standard Good Practice Recommendations Terms and conditions of residency which are issued to all people who live at Danesford Grange need to clearly identify who is responsible for fee payment and clearly identify the period of notice to be given should they change, in order to fully comply with recent care home legislation of September 2006 regarding fees It is recommended that consideration be given to the identified problems with the noise level of the call bell system.(identified at 06/07/06 inspection.) In order to improve standards in the home to minimise the risk of people living there from any infection, it is advised that the home carries out an infection control audit in line with Health Protection Agency guidance and carries out any remedial actions necessary to promote and maintain satisfactory infection control practices. Systems for the safekeeping of the monies and valuables of the people who live at the home need to be further developed so that the home has robust auditable records of all items held on behalf of its residents. 2 3 OP22 OP26 4 OP35 Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. Extracts may not be used or reproduced without the express permission of CSCI Danesford Grange Care Home DS0000022250.V340250.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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