CARE HOMES FOR OLDER PEOPLE
Grafton Lodge Grafton Road Oldbury West Midlands B68 8BJ Lead Inspector
Lesley Webb Unannounced Inspection 6th January 2007 10:15 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 Grafton Lodge DS0000034140.V325766.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. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Grafton Lodge Address Grafton Road Oldbury West Midlands B68 8BJ 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) 0121 559 3889 0121 559 0708 Sandwell Metropolitan Borough Council *** Post Vacant *** Care Home 36 Category(ies) of Dementia - over 65 years of age (36) registration, with number of places Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. All requirements contained within the pre-registration report of 13 January 2003 are met within the timescales contained within the action plan agreed between Sandwell Metropolitan Borough Council and the National Care Standards. Day care provision must not encroach on the facilities, staffing and services provided to residential service users One service user accommodated at the home may be DE. This will remain until such time that the service users placement is terminated. February 2006. 2. 3. Date of last inspection Brief Description of the Service: Grafton Lodge is owned by Sandwell Metropolitan Borough Council and is committed to providing an individual approach to care for older people with mental health needs, the majority being with moderate to severe forms of dementia. Grafton Lodge is situated 2 miles from Oldbury and within easy access of Blackheath, Dudley and Birmingham. The home is situated approximately 2 miles from the M5, junction 2. Rowley railway station is within walking distance and a number of bus routes (449, 88, 123) frequently pass the unit in Grafton Road. Local amenities are within walking distance of Grafton Lodge, these include a church, shops, post office, take away food outlets, golf course, public house, restaurants and a doctors surgery. Grafton Lodge has 36 single bedrooms, (including one en-suite room), these being in two 18 bedded units, one on each floor, with 5 beds being specific to respite care on the upstairs unit. The home offers a passenger lift, and has various aids and adaptations. To the rear of the property is a patio and garden, which provides residents with a pleasant outdoor area. Car parking space is available at the side of the home. The home has its own transport. A range of services are available at Grafton Lodge, which are detailed in the homes Service User Guide. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was undertaken by one inspector with the home being given no prior notice. During the visit time was spent formally interviewing staff, examining records and observing care practices before giving feedback about the inspection to the manager. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case tracking three individuals care provided at the home. For example the people chosen have differing communication and care needs, consist of male and female and have various cultural heritage. Two relatives of residents were present during the inspection. Both praised the service, paying particular attention to staff and management. All residents have moderate to severe forms of dementia so conversations were not appropriate. Additional time spent observing care practices, interactions between residents and staff and formally interviewing staff in order to assess needs being met and quality of service. Fees charged for living at the home are £467 per week. What the service does well:
When interviewing staff the inspector asked what the best thing about the home was. Responses include, “I really, really enjoy my job, enjoy working with these people, its rewarding. They might not be able to thank you but you know they are so grateful, they are really lovely” and “some residents hardly get any visitors, they have staff who come here and take the place of their families and try to make them happy”. These comments were reinforced when observing care practices and interactions between residents and staff. Throughout the inspection staff were observed treating service users with dignity and respecting their rights to privacy. For example staff were witnessed knocking on bedroom and bathroom doors before entering and talking in a respectful manner to service users. A member of staff was observed sitting at a dining table assisting/encouraging a resident to have something to drink. She spoke softly, reassuring the resident throughout the process. In the main records, conversations with staff and observation of care practices confirm that the health needs of residents are appropriately managed by the home. The case files sampled by the inspector all contained information evidencing that residents have access to health care and are registered with a GP and receive the services of other allied medical professionals such as Dental, Ophthalmic, Nursing and Chiropody.
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 6 When interviewing staff all demonstrated excellent knowledge and understanding of involving residents with dementia to make choices. For example one person explained, “if dementia is not advanced offer choices, ask if would prefer bath or a wash, show two items of clothes. However those with advanced dementia its really hard so we contact family members, find out likes and dislikes. When assisting with personal care, if a person is not responding we take that as their way of not wanting participate. We also look at changes in behaviours, information in care plans, gather information from as many places as possible”. Staff have excellent knowledge of supporting residents to complain and protecting from abuse. For example when asked how they support people with dementia to raise concerns or to complain responses included, “I would ask what they don’t like and what they do like. We had a lady last week who said she didn’t like the tea so I got her something else, I told manager and kitchen staff to make sure if it is on the menu again to make sure she has some thing else. Staff are really good like that. A lot of our residents don’t talk but might stop eating so I would try something else and tell the manager and insist some thing is done” and “we record everything in the daily entries so we know throughout day how they act, we know if they are low, if they are low just a day it might not be anything but if continues we would record, some will say miss family so we inform management, its on us to bring their grievances forward, if they are missing their family, don’t like food, its up to us to observe and report anything”. When asked how to protect residents from abuse responses included, “abuse comes in so many forms, bruising, skin changes, we have bruise charts, sexual abuse can be difficult so if change in mood, or becomes aggressive, shunning away from another client, refusing personal care from another member of staff, you might not be sure but keep your eye and report. If lose appetite this could be their way of saying I’m not happy. When working with other staff, if you think handling is a bit rough you must say so, if you see something even if you are not sure, you must report immediately and take action. Make sure our own staff treating residents in appropriate manor”. Management are proactive in identifying bad practice, sharing information to protect residents and view complaints and protection as a way of improving the quality of service provided at the home. Information supplied to the Commission for Social Care Inspection prior to the visit details eight adult protection investigations in the previous twelve months. All of these were initially identified by management and staff at the home who then referred to relevant agencies. The manager demonstrated to the inspector a commitment to report any incident of alleged abuse to ensure people with dementia living at the home are protected. As she explained the number of investigations may seem high but priority is protecting vulnerable adults. Despite poor numbers of staff receiving training all staff interviewed demonstrated excellent knowledge and understanding of the needs of people with dementia. For example when asked what can cause confusion to
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 7 someone with dementia responses included, “noise, alarms, or if another client is agitated, medication if not given can cause confusion, if sleep patterns change, constipation, ill health” and “when they first come here it’s a change of environment, being taken away from loved ones, infections, medication changes. Especially if doctors change medication we find behaviour differences so we go back and explain, being in different environment is usually hardest until they get to know us and their surroundings”. A range of quality assurance audits are undertaken including service user satisfaction surveys, external quarterly audits, random checks by the manager, regular monitoring of staff support and residents care packages. All information gained is then analysed and incorporated into an annual report that is linked to the business objectives for the service. Also as in the previous inspection systems for managing resident’s monies are good. Individual records are maintained of personal allowances held on behalf residents along with corresponding receipts. In addition to this safe checks are completed on every shift adding further protection to those living at the home. What has improved since the last inspection? What they could do better:
The two main areas where improvements must be made are the environment and staff training. Despite attempts to make the building appear homely the size and age of the building restricts efforts in this area. The home was built in the 1960’s and consists of long narrow corridors, many bedrooms that are small in size without en-suite facilities and bathrooms that are stark. Many door widths are not appropriate for moving and handling, there are no
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 8 separate activity rooms or areas where people with dementia can relax separate from the communal lounges and there appears to be no forward planning in place by the local authority in relation to meeting the needs of people with dementia and the impact the environment can have on this. The Commission for Social Care Inspection would not register this building if an application were to be made under current guidelines and legislation. In relation to the building a development plan for the building must be completed, with emphasis on meeting the needs of people with dementia. This must comply with relevant legislation and good practice guidelines. Also a programme of redecoration must be implemented for all areas of the building and an appropriate budget must be put in place for redecoration and systematic replacement of fittings and furniture. An investigation into the heating of the building must also be undertaken with remedial action taken resulting in appropriate temperatures being maintained. Corporately the arrangements for staff training are poor and result in ineffective use of management time. Records viewed and discussions with staff indicate that staff are restricted in terms of training they can undertake due to insufficient places available on training provided by the local authority. Work must continue to ensure all staff (including regular agency staff) hold an NVQ qualification level 2 or equivalent, or be working towards this and all staff (including regular agency staff) must undertake continence management, prevention of falls, dementia care and tissue viability training, with certificates maintained in the home. Other areas where improvements are required include ensuring the statement of purpose and service user guide contain all information as required in the Care Homes Regulations 2001, that care plans are completed in sufficient detail, that moving and handling assessments are service user focused, that systems are introduced to ensure residents have adequate supplies of medication and that appropriate action is taken in the event of medication not being supplied and that residents are given the opportunity to access the local community on a regular basis. 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. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although information regarding the home is available to prospective residents and their representatives, improvements will ensure they can be confident the home will be able to meet their needs. Residents have their needs assessed and a contract which clearly tells them about the service they will receive. Staff have excellent knowledge of residents needs. EVIDENCE: Progress has been made by the home to address requirements identified in the previous inspection. One previous requirement relating to the statement of purpose is now part met. The statement of purpose is in the process of being reviewed and upon examination of this document was found to contain the majority of information as listed in Schedule 1 of the Care Homes Regulations
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 11 2001, with only minor amendments required. Two previous requirements relating to the service user guide remain unmet. The manager explained that once the statement of purpose had been reviewed and amended the service user guide would be altered accordingly. A previous requirement to ensure all service users receive a contract/terms and conditions of residency is now met; with all case files sampled containing this document. Also since the last inspection a service user who was residing at the home who had been assessed as requiring nursing care has moved to a more appropriate setting, resulting in the home not providing a service to anyone it is not registered for. Residents are accepted for admission on the basis of a community care assessment and the homes own assessment undertaken by senior staff. Occasional emergency respite admissions are accepted on the assessment of the admitting Social Worker. When sampling resident’s files all contained assessments of needs, confirming that the homes policy regarding admission procedures is being complied with. Intermediate care is not offered at this home; therefore this standard is not applicable. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that residents receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Further improvements to some medication practices will enhance systems and offer greater protection to residents. EVIDENCE: In the main records, conversations with staff and observation of care practices confirm that the health needs of residents are appropriately managed by the home. The case files sampled by the inspector all contained information evidencing that residents have access to health care and are registered with a GP and receive the services of other allied medical professionals such as Dental, Ophthalmic, Nursing and Chiropody. It was also pleasing to find that residents weight records are now being maintained in full, addressing a
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 13 previous requirement. The manager produced new care planning documentation that is going to be introduced to the home once staff have received training explaining that this will enhance systems already in place. A previous good practice recommendation to introduce a more in-depth assessment of falls remain in place. The manager states that falls are monitored monthly with an analysis of treads completed which then results in manual handling risk assessments being reviewed. When examining the manual handling risk assessments the inspector found the format of these to be based on tasks undertaken by care staff and not on residents needs resulting in many areas of the document being incomplete. This was discussed with the manager who agreed a more suitable format should be introduced. In relation to a previous recommendation to introduce more in-depth medication assessments the manager explained that these form part of the initial assessment undertaken by the relevant social worker. Due to all residents having moderate to severe levels of dementia assessments indicate that they are not capable of self-medicating. This recommendation is therefore removed. When examining care plans the inspector found that these varied in terms of content and context. For example sections for intellect, culture and emotion in one person plan were blank and another persons plan did not contain specific instructions stating ‘ensure G is given the freedom to express herself within her surroundings’ and ‘communicate in a language G understands and at a pace she can cope with’. Other care plans however were detailed and comprehensive. The manager reiterated that the new care plans that are going to be introduced would address these deficits. A previous requirement to ensure all residents are given the opportunity to access hearing tests remains not met. The manager states this still needs to be worked on as part of normal health care monitoring. As at the previous inspection staff have excellent knowledge of residents needs and promoting privacy and dignity. Throughout the inspection staff were observed treating service users with dignity and respecting their rights to privacy. For example staff were witnessed knocking on bedroom and bathroom doors before entering and talking in a respectful manner to service users. Also a member of staff was observed sitting at a dining table assisting/encouraging a service user to have something to drink. She spoke softly, reassuring service user throughout process. These practices were further reinforced as the norm by staff when interviewed. Since the last inspection a written policy for care of the dying and how this may impact on service users residency at the home has been introduced. This now needs to be included in the service user guide to meet a previous requirement in full. It was noted by the inspection that the new policy appears very detailed and informative. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 14 Medication systems were examined and in the main appear appropriate. Medication is stored on each unit within appropriate lockable facilities. The home uses the Boots medication dispensing system for recording and storing medication and generally all records for medication entering, being administered and leaving the home appear appropriate. A photograph of each permanent resident was found to be in place along with recorded stock counts for PRN medication and fridge lines and controlled drugs are stored correctly. One prescribed eye medication was not dated when opened but the manager rectified this immediately. Records indicate that a resident has not received an item of medication for over a week, with no recorded explanation. The inspector investigated this with the manager stating the resident was recently admitted to the home after being in hospital. This person came from hospital with only a small supply of this medication, has moved out of the area where originally registered with a general practitioner (GP) resulting in the GP not willing to prescribe more medication. The manager states the home has been attempting to register the resident with a new GP but that this was taking time due to the Christmas period. The manager also states it is the social workers responsibility to ensure appropriate medication and that residents are registered with a GP as per the homes admissions procedure. The inspector instructed that home also have duty of care and that they must contact relevant departments to rectify situation immediately. The home was also instructed to telephone NHS direct explaining situation to ascertain if any adverse side effects of not having the medication administered placed the resident at risk and to take action in relation to any advise given. The only other issue found in relation to medication was that a prescribed cream had signatures missing for administration. The manager explained that this was an issue that continues to arise where care staff that administer creams forget to sign records. It is recommended that it be made a responsibility of the senior on each shift to check MAR sheets and ensure staff signatures are in place. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 15 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally residents are offered activities. Further improvements will enhance the quality of life residents receive. Residents are able to keep in contact with family, with the home proactively supporting them in this area. Residents receive a health, varied diet according to their assessed requirement and choice. EVIDENCE: Improvements to in-house activities have taken place. A person is now employed specifically for this purpose with evidence of some activities occurring. Further improvements would however enhance the quality of life for residents. A previous requirement to ensure residents are given the opportunity to access the local community on a regular basis is now part met. The manager states that an activity programme has been developed where a few events have took place but that these ceased due to a bereavement of the driver employed at the home. She did however confirm that a driver has now been recruited and a new activity schedule is to be produced. Due to all the
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 16 residents living at the home having moderate to severe dementia, activities in the community require one to one staffing levels. Staff confirmed that this impacts on the amount of activities offered, due to budgetary constraints, with many staff undertaking this role voluntary. It is strongly recommended that the allocation of funds be investigated and appropriate budgets put into place to further enhance the quality of life and service provision people can expect living at the home. The inspector viewed activity plans with individual records indicating these are not always being adhered to. Records indicate activities include writing Christmas cards, reminiscence, post cards, bingo and hairdresser visits. Records do not reflect staff comments in relation to activities undertaken when interviewed. For example one person explained, “they like music, I would say half like bingo, with a lot of help, reminiscence through the books. Some enjoy singing and clapping, we do that most nights. Get things out of the activity cupboard and reminisce. Sometimes we are really, really busy and never stop for the whole shift, but do try to make time for activities” and another “just a few like playing dominoes, lots love music, sometimes we bring in entertainers, some like dancing, one person likes football so is taken to the stadium and we keep him up to date with scores, another enjoys the horses so we get newspapers and put channel on so that he can watch. Most have short attention span so after couple minutes lose interest, so if playing skittles will do this for a couple of minutes then wander off”. When examining care plans in the downstairs unit inspector sat in the lounge/dining area indirectly observing residents and staff. A television was on in one part of the lounge and radio in another (having the potential to cause confusion to people with dementia). When examining care plans in the upstairs unit the inspector sat in the lounge/dining area again indirectly observing residents and staff. The television was on, with majority of residents sitting around the room. Staff brought a mixture of alcoholic and soft drinks, asking residents their preference. Staff confirmed this was a regular event on a Saturday evening. Residents appeared to enjoy this event, with people smiling and the inspector observed very good interaction between staff and residents. Staff knew residents preferences in relation to drinks and also who required assistance. Residents who had previously been sitting silent became animated, smiling and talking to staff. The home proactively supports residents to maintain contact with their families, with relatives confirming staff are friendly and keep them informed. A previous requirement to ensure advocacy details are included in the service user guide and displayed prominently throughout the home is now part met. This information was found to be displayed within the home but is still required to be included in service user guide. Residents are encouraged and assisted to arrive at choices about their daily routines such as choosing clothes, meals and activities. In addition to this residents are encouraged and supported to bring items of personal belonging into the home on admittance, with all files
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 17 sampled containing inventories detailing these items. When interviewing staff all demonstrated excellent knowledge and understanding of involving residents with dementia to make choices. For example one person explained, “if dementia is not advanced offer choices, ask if would prefer bath or a wash, show two items of clothes. However those with advanced dementia its really hard so we contact family members, find out likes and dislikes. When assisting with personal care, if a person is not responding we take that as their way of not wanting participate. We also look at changes in behaviours, information in care plans, gather information from as many places as possible”. A comprehensive menu is in place that details choices at all meal times, including a range of hot and cold meals, drinks and snacks (this meets in full requirements identified in the previous inspection). The menu includes consideration for diets including vegetarian and diabetic. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 18 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 and 18. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure, are protected from abuse and have their legal rights protected. Staff and management have excellent knowledge of complaints and protection, being proactive in these areas, viewing them as ways of improving the quality of service provided at the home. EVIDENCE: Staff have excellent knowledge of supporting residents to complain and protecting from abuse. For example when asked how they support people with dementia to raise concerns or to complain responses included, “I would ask what they don’t like and what they do like. We had a lady last week who said she didn’t like the tea so I got her something else, I told manager and kitchen staff to make sure if it is on the menu again to make sure she has some thing else. Staff are really good like that. A lot of our residents don’t talk but might stop eating so I would try something else and tell the manager and insist some thing is done” and “we record everything in the daily entries so we know throughout day how they act, we know if they are low, if they are low just a day it might not be anything but if continues we would record, some will say miss family so we inform management, its on us to bring their grievances forward, if they are missing their family, don’t like food, its up to us to observe
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 19 and report anything”. When asked how to protect residents from abuse responses included, “abuse comes in so many forms, bruising, skin changes, we have bruise charts, sexual abuse can be difficult so if change in mood, or becomes aggressive, shunning away from another client, refusing personal care from another member of staff, you might not be sure but keep your eye and report. If lose appetite this could be their way of saying I’m not happy. When working with other staff, if you think handling is a bit rough you must say so, if you see something even if you are not sure, you must report immediately and take action. Make sure our own staff treating residents in appropriate manor”. The home uses the local authority Social Services Departments complaints, compliments and comments’ procedures, a copy of which was seen to be available, this containing clear timescales for response to complaints within a 28-day timescale. A Previous requirement to ensure a record of all issues/complaints raised by staff on behalf of residents is maintained, including actions taken and outcomes is now met in full, with comprehensive records now in place. An abundance of compliments (approximately fifty) have also been received in the twelve-month period since the last inspection mainly from relatives of residents regarding levels of care, meals and parties such as birthdays arranged by the home on behalf of residents. Management are proactive in identifying bad practice, sharing information to protect residents and view complaints and protection as a way of improving the quality of service provided at the home. Information supplied to the Commission for Social Care Inspection prior to the visit details eight adult protection investigations in the previous twelve months. All of these were initially identified by management and staff at the home who then referred to relevant agencies. The manager demonstrated to the inspector a commitment to report any incident of alleged abuse to ensure people with dementia living at the home are protected. As she explained the number of investigations may seem high but priority is protecting vulnerable adults. A previous requirement to ensure all staff undertake physical aggression training (with certificates maintained within the home) is now part met with many staff having now completed this. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 20 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 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home is dated, in parts institutionalized and is not suitable for people with moderate to severe dementia. Although staff attempt to make the building appear comfortable, it does not present as homely. EVIDENCE: Despite attempts to make the building appear homely the size and age of the building restricts efforts in this area. The home was built in the 1960’s and consists of long narrow corridors, many bedrooms that are small in size without en-suite facilities and bathrooms that are stark. Many door widths are not appropriate for moving and handling, there are no separate activity rooms
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 21 or areas where people with dementia can relax separate from the communal lounges and there appears to be no forward planning in place by the local authority in relation to meeting the needs of people with dementia and the impact the environment can have on this. The Commission for Social Care Inspection would not register this building if an application were to be made under current guidelines and legislation. Many areas of the building require redecorating/refurbishing. The manager states that funds are available to refurbish the kitchen (this will address requirements made by the Environmental Health department) but due to the age and size of the building budgets are constantly being used to address immediate repairs and safety issues. Both kitchettes have been cleaned and redecorated since the last inspection, double electric sockets have been fitted in a few of the bedrooms and the manager also states funds have been agreed to replace/upgrade all alarms in bedrooms. Water temperatures are now being regularly checked to ensure staff are able to practice good hand washing under safe, hot running water. A number of double glazing units that show signs of having failed have been replaced, with the manager confirming others have been reported as faulty but as yet not replaced. A previous recommendation to install a sluice disinfector remains in place. The manager states funds have been agreed to improve some areas of the building but is not sure if this will be included. A tour of the building was undertaken. Many areas of the home appear worn and dated, with wall being chipped and damaged, paintwork stained and items of furnishing appear old. A kitchen door was seen to be wedged open (potential fire hazard), a strong odour was apparent on one of the wings, showers are out of commission due to Legionella bacteria and communal wheelchairs were seen to be stored in bathrooms. Heat throughout the building was very oppressive with many beds having only a sheet due to this. The manager explained that the heat for the home is regulated centrally; with little the home can do to rectify this (a member of staff was however sent to the boiler room to see if a thermostat was located there that could reduce the heat). No change in temperature was noted throughout the inspection. The laundry room was inspected and as with many other areas of the building found to be requiring attention. Areas of the walls are chipped requiring repair and decoration, equipment was out of use due to being broken and a build up of lint was apparent around the drying area. The inspector explained that maintenance of this area should be included in the cleaning schedule with records maintained demonstrating compliance. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 22 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although staff are not trained in sufficient numbers they have excellent knowledge and understanding of the needs of people with dementia. Improvements to the numbers of staff or the reduction of service users living at the home would enhance the quality of service provided. EVIDENCE: Although staffing levels conform to guidance from the department of health, improvements or reductions in numbers of service users will allow for an increase in the quality of service provided. Six care staff are on duty each shift during the day and early evening (three on each unit) plus management spend a proportion of their time working on the floor. Night staff consists of one senior and two care assists. Currently there is also an additional night care assistant due to previous adult protection measures. It is strongly recommended that this be made a permanent situation to ensure the safety and wellbeing of the people residing at the home, all of whom have moderate to severe levels of dementia. The manager explained that the council might be looking to withdraw this when the new emergency call system is in place. The inspector is of the view that this would not be appropriate as the call system
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 23 will alert staff to people requiring assistance but would not reduce the amount of assistance people require. For example if someone falls or requires assistance with personal care during the night two care staff might need to complete this resulting in one member of staff being available to care for the remaining thirty five residents. In addition to care staff the home employs laundry, domestic and kitchen staff. Examination of records, discussions with staff and observation of care practices indicate that whilst two staff are allocated on each unit allowing for personal care to be undertaken, the range of activities and quality of care provided would be greatly improved if staffing levels were to increase. Staff spoken to confirmed that the majority of their time is spent completing personal care and offering assistance at mealtimes. For example one person stated, “staffing levels are not enough when one person needs assistance by two staff and staff are needed to be in both lounges at all times, I really believe if extra staff were on duty some accidents would not happen and we would be able to give better quality of life to residents”. It was also noted by the inspector that within the minutes of two of the recent adult protection meetings reference is made to staff levels having the potential to impact on service deliver. Recruitment is undertaken in line with the local authorities equal opportunities policy and monitored by Human Resource department, which retains the staff files centrally with a copy file held locally. Upon inspection of five staff files all were found to contain all required information as listed in Schedules 2 and 4 of the Care Homes Regulations 2001. In addition to this records of agency workers include a specific induction checklist along with evidence of enhanced CRB disclosures, qualifications, references and experience (meeting a previous requirement). Since the last inspection the written policy for volunteers has been amended to make reference to the requirement of CRB/POVA disclosures (also meeting a previous requirement). Corporately the arrangements for staff training are poor and result in ineffective use of management time. Records viewed and discussions with staff indicate that staff are restricted in terms of training they can undertake due to insufficient places available on training provided by the local authority. Despite poor numbers of staff receiving training all staff interviewed demonstrated excellent knowledge and understanding of the needs of people with dementia. For example when asked what can cause confusion to someone with dementia responses included, “noise, alarms, or if another client is agitated, medication if not given can cause confusion, if sleep patterns change, constipation, ill health” and “when they first come here it’s a change of environment, being taken away from loved ones, infections, medication changes. Especially if doctors change medication we find behaviour differences so we go back and explain, being in different environment is usually hardest until they get to know us and their surroundings”. Previous requirements relating to training remain either partly met or not met. The manager confirmed that the numbers of staff who hold a national
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 24 vocational qualification do not meet national minimum standards and that further work is required to ensure all staff receive guidance in continence management, prevention of falls and tissue viability. The manager confirmed that the majority of staff have undertaken dementia awareness training but are awaiting certificates to validate this. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 25 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): 31,33,35,36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is based on openness and respect, with effective quality assurance systems in place ensuring the home can measure its aims and objectives. Generally health and safety is well managed. EVIDENCE: Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 26 A previous requirement to submit an application to register the manager remains unmet. However the manager made a commitment to do this by the end of January 2007. The acting manager has been in post since November 2005 and holds national vocational qualifications level 3 and 4 and the registered managers award. Observations throughout the inspection demonstrate competence as a manager of an older persons establishment. As at the previous inspection an abundance of compliments were received about the manager and the support she has given to staff. As in the previous inspection quality assurance systems are good. A range of quality assurance audits are undertaken including service user satisfaction surveys, external quarterly audits, random checks by the manager, regular monitoring of staff support and residents care packages. All information gained is then analysed and incorporated into an annual report that is linked to the business objectives for the service. The inspector was pleased to find that the majority of staff that were interviewed understood the importance of a quality assurance system, giving examples such as, “its monitoring to ensure everything is carried out to a good standard”. Also as in the previous inspection systems for managing resident’s monies are good. Individual records are maintained of personal allowances held on behalf residents along with corresponding receipts. In addition to this safe checks are completed on every shift adding further protection to those living at the home. One previous requirement relating to supervisions is part met. All staff files sampled contained evidence that this is occurring, however the frequency was found to vary. The manager states a supervision schedule is to be introduced so that monitoring can be effective. Generally health and safety is well managed. One previous requirement relating to health and safety training is part met with evidence that training in first aid, moving and handling, infection control, food hygiene and fire takes place. Improvements to the numbers of staff receiving training in these areas is required before this requirement can be met in full. Risk assessments and data sheets for products regulated under COSHH are in place and appropriate storage is maintained. The inspector recommends that information relating to products be stored near to products for ease of reference. All other records pertaining to the management of health and safety appear appropriate. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 27 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 2 1 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 28 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 OP1 Regulation 4,5,6 Requirement The statement of purpose must include all information as listed in Schedule 1 of the Care Homes Regulations 2001- part met. Requirement originally made February 2006. The service user guide must include all information as detailed in Regulation 5 of the Care Homes Regulations 2001not met. Requirement originally made February 2006. Information regarding the range of trial visits to the home must be included in the service user guide – not met. Requirement originally made February 2006. A written policy for care of the dying and how this may impact on service users residency at the home must be introduced and included in the service user guide – part met. Requirement originally made February 2006.
Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 29 Timescale for action 01/03/07 2 OP1 4,5,6. 12(1)(2) 01/03/07 3 OP7 15 4 OP8 12(1) Advocacy details must be included in the service user guide and displayed prominently throughout the home – part met. Requirement originally made February 2006. All residents must have a plan of care completed in sufficient detail for all their health, personal and social care needs All residents must be given the opportunity to access hearing tests, with records maintained – part met. Requirement originally made February 2006. Moving and handling assessments must be completed for all residents, and the format used be service user focused. Systems must be introduced to ensure residents have adequate supplies of medication and that appropriate action is taken in the event of medication not being supplied. Service users must be given the opportunity to access the local community on a regular basis – part met. Requirement originally made September 2005. CSCI must be supplied with a written explanation that defines ‘formal’ applications to access resident’s records as detailed in the service user guide – not met. Requirement originally made February 2006. All staff (including regular agency staff) must undertake physical aggression training, with certificates maintained at the home - Part met. Requirement originally made September 2005. A development plan for the
DS0000034140.V325766.R01.S.doc 01/03/07 01/03/07 5 OP9 12(1)(a) 01/02/07 6 OP13 12(4) 01/02/07 7 OP14 12(3) 01/03/07 8 OP18 10(1) 01/03/07 9 OP19 23 01/03/07
Page 30 Grafton Lodge Version 5.2 16(1)(2) building must be completed, with emphasis on meeting the needs of people with dementia. This must comply with relevant legislation and good practice guidelines. A programme of redecoration must be implemented for all areas of the building. An appropriate budget must be put in place for redecoration and systematic replacement of fittings and furniture. An investigation into the heating of the building must be undertaken with remedial action taken resulting in appropriate temperatures being maintained. Fire doors must not be wedged open. Appropriate self-closing devises must be fitted to any door requiring to left open. The home must address all requirements made by the Environmental Health Department - Part met. Requirement originally made September 2005. The responsible person must provide a second double electric socket in service users bedrooms - Part met. Requirement originally made August 2004. Damaged walls in the laundry must be repaired and decorated. The regular removal of lint must be included in the cleaning schedule with records maintained demonstrating compliance. All staff (including regular agency staff) must hold an NVQ level 2 or equivalent, or be
DS0000034140.V325766.R01.S.doc 10 OP24 23(2) 01/03/07 11 OP26 23(2)(b) 01/03/07 12 OP28 18(1) 01/03/07 Grafton Lodge Version 5.2 Page 31 13 OP30 18(1) 14 OP31 9 15 OP36 18(2) 16 OP38 13(3) working towards this – not met. Requirement originally made February 2006. All staff (including regular agency staff) must undertake continence management, prevention of falls, dementia care and tissue viability, with certificates maintained in the home - Part met. Requirement originally made September 2005. An application to register a manager must be made to the Commission for Social Care Inspection – not met. Requirement originally made September 2005. The registered person must ensure that staff receive a minimum of six supervisions each year and devise a plan to demonstrate how this will be delivered - Part met. Requirement originally made February 2005. All staff must undertake first aid, moving and handling, infection control, food hygiene and fire training, with certificates maintained in the home - Part met. Requirement originally made September 2005. 01/03/07 01/02/07 01/03/07 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that a more in-depth assessment of falls be undertaken using a recognised assessment tool. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 32 2 3 4 5 OP9 OP12 OP26 OP27 6 7 OP27 OP38 It is recommended that senior staff on each shift be made responsible for checking care staff have signed MAR sheets when administering prescribed creams. It is strongly recommended that the allocation of funds be investigated with budgets put into place for in-house and external activities. It is recommended that a sluice disinfector be provided to avoid the need to chemically disinfect commodes. It is strongly recommended that additional care staff be deployed during the day in order that residents can have the opportunity to participate in external activities and to increase the quality of service delivery. It is strongly recommended that the temporary increase in night staff be made permanent to ensure the safety and wellbeing of people residing at the home. It is recommended that COSHH data information be stored near to products for ease of reference. Grafton Lodge DS0000034140.V325766.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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
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