Inspection on 15/11/05 for Grange Court

This inspection was carried out on 15th November 2005.

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

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

Other inspections for this house

Grange Court 14/12/06

Grange Court 03/05/05

Grange Court 23/09/04

Grange Court 07/05/04

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

CARE HOMES FOR OLDER PEOPLE Grange Court Church Gardens Garforth Leeds LS25 1HG Lead Inspector Catherine Paling Unannounced Inspection 15th November 2005 12:30 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 Grange Court DS0000033226.V262097.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. Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grange Court Address Church Gardens Garforth Leeds LS25 1HG 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) 0113 2864845 0113 2864845 Leeds City Council Department of Social Services Jane Hawkhead Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2005 Brief Description of the Service: Grange Court is a residential home providing personal care for men and women over pensionable age. There are 30 permanent places with three places available for respite care. The home is on two floors, with a passenger lift providing access to both floors. All bedrooms are single with their own washbasin; there are no en-suite facilities. There is a range of communal toilet and bathing facilities throughout the home. The large communal dining room is on the ground floor, together with a choice of lounge areas, one of which is a designated smoking area. The home is situated off the main shopping street in Garforth town centre, close to local amenities including the library, medical centre, shops and post office. Garforth is a close-knit community, about 10 miles from the centre of Leeds. Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was in May 2005. This was an unannounced inspection by one inspector who spent four and three quarter hours at the home. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care for the residents and to assess progress on meeting the requirements and recommendations made at the last visit. The methods used at this inspection included looking at records; observing working practices; talking to staff and residents; and discussion with the manager. Comment cards were left at the home for residents and relatives inviting them to share their views of the home with the CSCI. Any comments received would be shared with the manager anonymously. The term residents and not service users will be used throughout the report, at their request What the service does well: What has improved since the last inspection? What they could do better: The manager must make sure that the care records do provide clear evidence of the assessed needs of the residents and of the care provided. Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 6 Residents admitted for respite care should have their needs reassessed at each admission. These records should also provide detail of how their care needs can be met. The manager needs to review the activity provision to ensure that appropriate stimulation and leisure opportunities are available for all residents. The reconvening of the residents committee is to be encouraged. 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. Grange Court DS0000033226.V262097.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 Grange Court DS0000033226.V262097.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): 3 and 5. (Standard 6 is not applicable) The assessment processes do not guarantee that the needs of residents can be met. EVIDENCE: Pre-admission information provided to the home was in the form of the local authority care plan and the Easy care document. Overall the information was insufficient to be able to guarantee that the needs of the residents could be met at the home. This was particularly with regard to those residents admitted to the home for respite care. There was evidence within the records to indicate that residents visited and spent time at the home before being admitted for respite care. A recommendation has been made. Grange Court DS0000033226.V262097.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): 7. Overall the home is good at meeting the care needs of the residents but records do not consistently provide evidence of this. EVIDENCE: Permanent residents have individual plans of care in the form of a Lifestyle plan. The standard of recording is variable. There is some very good personal detail in some plans clearly indicating personal preferences about care needs. Others provide vague instructions and are not clear about needs. For example, ‘offer a choice of how and when she would like a bath’ without specific detail about what intervention would be needed from staff. Review and update of care plans was not clear in that entries were not dated or signed. In the case of a resident admitted for respite there was no current information about care needs and needs had not been re-assessed at each admission. There was little information about the health or personal care needs of this resident. In the case of another resident admitted for regular respite there had been an update following a stroke. This update could have been further improved with the addition of more specific detail. For example, ‘needs full input’ for personal care does not provide sufficient instruction for staff on how to meet the needs of the resident. Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 10 Risk assessments had not always been completed. For example, nutritional risk assessments and falls risk assessments had not been completed for all residents. Daily records were kept but issues identified within the daily records, such as a resident needing additional fluids or care to prevent skin damage did not generate a plan of management. Some Lifestyle plans had been signed by residents, this was not always the case. However, it was clear from discussion with staff and residents that staff did discuss care needs with the residents. Care staff were knowledgeable about the individual care needs of the residents who said that they felt well looked after by the staff. Records should provide evidence of the care provided. A requirement has been made. Grange Court DS0000033226.V262097.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): 12. Residents are encouraged to participate in social and leisure activities. EVIDENCE: Residents spoken with were satisfied with the lifestyle they experienced at the home. Records also indicated that staff were aware of the preferences of residents. Care staff offered a limited range of activities and one resident said that she particularly enjoyed the quizzes and she wished there was more of this type of activity. There is no residents’ committee at the moment. One member of the care staff was looking into re-convening these meetings. This would be a means of further enabling residents to be more involved in the arrangements of the entertainment and activities programme. There has previously been an active resident’ group at the home. Grange Court DS0000033226.V262097.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): 16. There is a robust complaints procedure and residents are confident that complaints will be taken seriously. EVIDENCE: The complaints policy was clearly displayed at the home and information on how to make a complaint was provided in different languages. Those residents spoken knew how they would make a complaint and who to complain to. The manager keeps a log of complaints. There have not been any recent complaints. Grange Court DS0000033226.V262097.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): 21 and 26. The home provides a safe and well-maintained environment. Systems are in place to protect the residents against the risk of cross infection. EVIDENCE: The refurbishment of the sanitary facilities had been largely completed. This work has been carried out to a high standard providing excellent sanitary facilities for residents. All areas are large enough to allow for full assistance by staff. Ceiling tracking has also been fitted to allow for mechanical assistance where that is needed. Only personal laundry is carried out on site. The laundry was well organised and all residents have a personalised basket for their laundry. Hand washing facilities were provided in the laundry and in all the communal areas. Staff all receive training in the prevention of cross infection by means of a distance learning package. Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29. The numbers of staff were sufficient to meet the needs of the residents. Staff are trained and competent to do their jobs. The recruitment procedures protect the residents. EVIDENCE: The staffing situation has improved since the last visit with the return from sick leave of one care officer the appointment of another. Some care staff vacancies have been filled and recruitment is ongoing. Regular agency staff are used to make sure that staffing levels are maintained at a safe level. The care staff team is committed to training and 75 of the care staff team have achieved their NVQ level 2 in care. There is a clear route for care staff from induction and foundation training towards undertaking NVQ. The recruitment function is carried out centrally with managers involved in the interview process on a rotational basis. The manager said that staff do not take up post until all the required checks have been completed. Copies of recruitment information held at the home on individual files provided evidence of this. Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 15 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): 31,33, 35 and 38. The home is well managed. The interests of the residents are seen as very important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager is experienced and provides clear leadership to staff. There is a clear commitment by the manager and her staff to safeguarding the best interests of the residents. This is evident from discussion with staff and residents. Liaison with residents and their families is informal. The manager and the senior staff are accessible to residents with the more mobile residents calling in at the office to talk with the manager. During the recent refurbishment work at the home the manager made sure that she spoke with residents and families to keep them up to date with developments. There is no residents Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 16 committee currently. A member of the care staff was looking into re-convening this previously active group. Some residents manage their own finances and look after their pocket money. There are lockable facilities in the bedrooms for the safe keeping of valuables. Other residents hand small amounts of money to staff to keep in the safe. There are clear records of all residents’ money and the home is subject to audit. All new staff are given fire instruction and regular fire drills are held for all staff, including the night staff. The names are recorded of those who have taken part in the drills. Regular checks are made of the alarm system. There has been a recent fire safety check by the fire service and some outstanding issues were identified although overall progress has been made. It was identified at this visit that two of the linen store cupboards did not have smoke detectors fitted. The manager was asked to make arrangements to address this oversight. Records are kept of accidents occurring to residents and the manager keeps a running log of accidents to try to identify any trends. All staff undergo health and safety training and information is displayed about the responsibilities of the individual. Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 17 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 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X 3 X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 15 Requirement The individual records must consistently provide detail and evidence of care. The residents and/or their representatives must be involved in the development of the care plan which must be reviewed on a monthly basis. (Previous timescale of 7/03/05 not met) The residents must be consulted about a programme of activities to provide stimulation and leisure, taking into account their differing abilities. Timescale for action 01/03/06 2. OP12 16(2)(n) 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations All residents should have their needs fully assessed prior to admission to the home. Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Grange Court DS0000033226.V262097.R01.S.doc Version 5.0 Page 20 - 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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