Inspection on 28/10/05 for Danesford Grange Care Home

This inspection was carried out on 28th October 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

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 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 Nursing And Residential Home Kidderminster Road Bridgnorth Shropshire WV15 6BW Lead Inspector Joy Hoelzel Unannounced Inspection 28th October 2005 01:30 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 Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 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 Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Danesford Grange Nursing And Residential Home Kidderminster Road Bridgnorth Shropshire WV15 6BW Address 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 Mrs Joan Thomas Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 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. 17th August 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Danesford Grange is a care home providing accommodation, personal and nursing care for thirty two older people. It is privately owned and 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. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over three hours on Friday 28th October 2005 and is the second of the two statutory inspections for 2005/06. Thirty people are currently residing at the home, the manager was on the premises and staffing numbers were at the agreed levels. The home was generally busy with staff assisting service users with personal care and family, friends and the general practitioner were visiting. Three care files were examined together with supporting documents. Discussions were held with service users, staff and management and a tour of the home was conducted. A single occupancy room was inspected for the proposed registration for use as an additional bedroom. What the service does well: What has improved since the last inspection? The management and leadership approach has greatly improved. New documentation has been implemented into the care planning process and a revised system for pressure area prevention and treatment has been adopted. Door guards have been installed where there is a need or preference for doors to remain open. Amendments have been made to the staffing complement particularly at peak activity times. Arrangements are in place for arranging and facilitating social and leisure activities based on the preferences of the current service users. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 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 And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: This set of standards was examined at the last inspection in April 2005. There have been no changes to the admission procedure. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 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 the following standard(s): OP 7, 8, 9, 10 Improvements have been made to the care planning process, there is a clear and consistent system in place that provides staff with the information they require to meet service users needs EVIDENCE: Each service user has an individual plan of care initially based on the preadmission assessments. Three service users care files were examined and evidenced that service users and /or their representatives are now being involved in the planning and review process. The plans are being reviewed at least monthly or more frequently as care needs change. The documentation and recording of the prevention and treatment of pressure areas has greatly improved and the staff must be commended for implementing the revised system. The care plan of a service user requiring regular treatment for a pressure ulcer was seen to be comprehensive, included clear instructions for the type and the frequency of the dressing changes and clearly outlines the improvement to the area. Changes have been made to the medication administration system; the manager stated that the policy and procedure for this task is currently under review. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 10 Information recorded in the controlled drug register and on the Medication Administration Record accurately cross referenced. Latin abbreviations are being used when handwriting the dispensing instructions on the Medication Administration Record, it is recommended that the full instructions are transcribed as stated on the dispensing labels (i.e. twice daily, not BD). Staff were observed to be addressing service users in the correct manner, however, on the tour of the premises it was clear that the privacy of service users using the toilet is not upheld. The toilet door was ajar with no indication that the toilet was in use. The information notice on the door was not in use and there was no appropriate locking facility on the door to ensure that privacy and dignity are upheld at all times. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 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 the following standard(s): OP12, 15 Staff work in close liaison with service users and their relatives to understand their individual lifestyles and preferences. EVIDENCE: Two staff have been allocated the responsibility for organising social and leisure activities. One staff member discussed the forthcoming Christmas activities planned and the leisure opportunities offered to service users at times during the week. A physiotherapist visits every two weeks, there are plans to commence aromatherapy and massage sessions. One service user was reading the local evening paper and was discussing the contents. Other service users were watching television, listening to music either in their private rooms or in the communal areas. A weekly menu is displayed on the dining tables and offers a set meal, with alternatives offered when required. The kitchen was well stocked with dry goods, fresh fruit and vegetables. It was noted that only semi skimmed milk was available. Full fat milk must be offered to all service users with alternatives provided for personal or dietary reasons. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 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 the following standard(s): OP16, 18 Concerns or complaints are dealt with promptly and professionally EVIDENCE: The home has a complaints procedure and a book is used for the recording and logging of all concerns and complaints, includes the action needed and any further action that may be required. No complaints have been sent directly to Commission for Social Care Inspection since the last inspection in April 2005. The requirements made following the past vulnerable adult investigation have been complied with and continue to be ongoing for new starters. This investigation is now closed. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 13 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): OP19, 23,24,26 Improvements have been made in ensuring the safety of service users and staff. However the lack of basic facilities continues to undermine privacy and dignity standards. EVIDENCE: Door guards have been fitted where there is a need for doors to remain open. The manager stated that the installation of the door guards is ongoing. A variation application form has been received and includes the possible registration of one new single occupancy bedroom. This room was inspected during this visit. The size of the room is above the national minimum standards. The following is needed before the room can be registered • A satisfactory report from the fire officer • A suitable locking facility on the bedroom door • The cracked window pane must be replaced • Security blocks are needed on the sash windows • An additional easy chair. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 14 The manager and administrator were advised of these additional items. The agreement of the offer of a lockable facility on service users private rooms has been included in the care plan which has been signed by the service user and/or representative. 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 is outstanding from the previous inspections and the agreed date of compliance of 31st October 2005 has not been met. 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. The agreed date of 31st October 2005 has not been met. The manager stated that an ‘appliance has been planned’ but was unsure of the installation date. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 15 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): OP27 Improvements have been made to the staffing arrangements particularly at peak periods. EVIDENCE: Staffing levels at the time of the inspection were – 1 manager, 1 deputy manager, and six care staff. Administration and catering staff were additional. The manager stated that amendments have been made to the staffing arrangements with additional staff available during peak times. These changes ensure that staff are available to assist service users at times suitable to the individual. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 16 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): OP 31,33,35,38 Improvements have been made in the day-to-day leadership and management. The home is managed by a competent manager who leads the staff group with confidence. EVIDENCE: Improvements were noted with the management structure, staff are now being allocated areas of responsibility and staff were observed to be working and interacting well. The manager stated that she felt there was a more structured and organised approach to the day-to-day running of the home. An administrator has been recruited to assist with non-nursing responsibilities. A multichoice questionnaire has recently been sent to service users, relatives and staff, the findings of which have been audited and a report is being produced. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 17 Service users personal allowances held at the home are kept in a locked safe in the main office. All monies are kept in separate, individually named wallets with individual recording sheets documenting each transaction. The manager carries out monthly audits. All monthly safety checks are carried out by a nominated contractor and records kept. The manager stated that the risk assessment for the safe and appropriate use of bed rails is under review. Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 2 2 X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement The registered person must ensure that the dispensing instructions for all medications are written out in full. Latin abbreviations must not be used. 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 Previous timescale not met. The registered person must ensure that each toilet and bathroom door has a suitable locking facility to ensure a person’s privacy and dignity is upheld. The registered person must ensure that service users are offered full fat milk, alternatives to be offered when there are personal or dietary reasons. Doors to service users private accommodation must be fitted with locks suited to service users capabilities and accessible to staff in emergencies. DS0000022250.V262531.R01.S.doc Timescale for action 30/11/05 2 OP9 13(2) 30/11/05 3 OP10 12(4)(a) 30/11/05 4 OP15 16(2)(i) 30/11/05 5 OP24 12(4) 30/11/05 Danesford Grange Nursing And Residential Home Version 5.0 Page 20 6 OP24 12(4) 13(4)(a) (b)(c) 13(3), 16 (2)(j) 7 OP26 Previous timescale not met. Service users are provided with keys unless their risk assessment suggests otherwise Previous timescale not met. Sluicing disinfectors are required in areas of the home where there is a need to dispose of bodily waste. Previous timescale not met. 30/11/05 30/11/05 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 Standard Good Practice Recommendations Danesford Grange Nursing And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Wolverhampton Area Office 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 And Residential Home DS0000022250.V262531.R01.S.doc Version 5.0 Page 22 - 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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