Inspection on 28/02/06 for Grange Court

This inspection was carried out on 28th February 2006.

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 05/03/09

Grange Court 25/03/08

Grange Court 04/09/07

Grange Court 09/08/06

Grange Court 08/09/05

Grange Court 02/03/05

Grange Court 11/02/05

Grange Court 20/12/03

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

CARE HOMES FOR OLDER PEOPLE Grange Court Station Road Baildon Shipley West Yorkshire BD17 6HS Lead Inspector Stevie Allerton Unannounced Inspection 28th February 2006 10:20 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 DS0000001244.V266381.R01.S.doc Version 5.1 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 DS0000001244.V266381.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grange Court Address Station Road Baildon Shipley West Yorkshire BD17 6HS 01274 531222 01274 531222 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) Mr Ronald Berry Mrs Doreen Berry Belinda Cook Care Home 30 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (30) Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: Grange Court is a family run concern, providing a thirty bedded home for elderly people. It is situated on the outskirts of the village of Baildon, Shipley West Yorkshire. Grange Court is a former coaching inn, with parts of the building dating to the fifteenth century and it still retains many of the original features. Over the years various alterations have been undertaken to make the home more accessible. All bedrooms are located on the first and second floors, the floors being accessed via a passenger shaft lift or staircase. There is a mix of double and single rooms available with disabled access via a ramp to the front of the building. Fees cover the costs of full accommodation, care and laundry facilities, but do not include chiropody, hairdressing and personal copies of newspapers and other personal requirements. Residents may bring in furniture and electrical items, though appliances are inspected for safety before use. All meals can be served in residents own room or in the dining area. Refreshments, tea/coffee and light snacks are available at any time of the day or night and relatives of residents are encouraged to share food at the home to promote a homely atmosphere. In each residents room, a plug point is available for a television and individual telephone lines can be arranged on request. Support services are in place with a choice of General Practitioners, chiropodist, dentist and optician. Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place without prior announcement and was conducted by one inspector over a five-hour period. This was the second inspection to be carried out at this home during the year ending 31st March 2006, the previous visit being an unannounced inspection in September 2005. The Registered Manager was on duty and available throughout this inspection, supported by Steve Wiggins, the Operations Manager. Mr Michael Berry attended for feedback at the end of the inspection. This was the first visit by this inspector to the home. Policies, records and documents were seen, a tour of the building was carried out and staff were observed as they attended to service users. One member of staff was spoken to individually, and discussions took place with 6 service users in the communal areas. What the service does well: What has improved since the last inspection? The ground floor bathroom has been refurbished since the last inspection. This has been done to a very good standard and the finishing touches have been appreciated by the service users. Arrangements have been made for the staff to receive training in adult protection in the near future. Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 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. Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 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 DS0000001244.V266381.R01.S.doc Version 5.1 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 Service users are properly assessed prior to admission, thus ensuring that their needs can be met at this home. EVIDENCE: Three service users’ care records were selected, reflecting a range of care need and length of time since admission. All of the care files contained assessment information, which had become the basis of each person’s individual care plan. A 72-hour initial care plan was seen to be in place for a newly admitted service user. Staff were using this period to assess the service user further and build up a more detailed care plan in response. Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 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 & 10 Service users’ health and personal needs are well covered by the care plans in place, but more detailed plans of how staff support individuals with their social care need to be considered. Service users are treated with respect as individuals. EVIDENCE: Care plans reflected the current health and personal care needs of the service users, but were not as strong in identifying social care needs, which the Manager recognised as a weakness. She has purchased a resource to help her develop the care plans to include more about social care. Staff were observed as they attended to service users in the communal areas. They spoke to service users respectfully, but also with a warmth that comes from knowing the person well. Service users confirmed in discussion that they felt well cared for and had confidence in the staff team. Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 Page 10 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 & 14 The range of activities and pastimes offered provides some good social opportunities for the service users; however, it was not clear whether or not these meet the service users’ needs, as these had not been identified in the care planning process. Service users are asked their opinions and have choice in their daily lives. EVIDENCE: There is a programme of activities during the week, which service users can choose to take part in or not. Some prefer to stay in their own rooms and are able to exercise that choice. A support assistant is designated to lead the activities, along with other staff, some of whom have talents with crafts or manicures. Photograph albums provide records of happy times, such as the PAT dog visits, or the party held to celebrate the Queen’s Jubilee. There is a minibus available for short trips, for example to the theatre. Service users’ meetings take place monthly; there was a poster displayed, advertising the next meeting later that week. Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 Page 11 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): 18 Steps are being taken to ensure a greater level of protection for vulnerable service users. EVIDENCE: The staff team have not yet received training in adult protection, but an external trainer has been engaged to come in for two sessions during April, covering all of the staff team. The Manager said that this would be completed by 1st May. Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 Page 12 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 The bathroom facilities have been upgraded recently and provide a good standard for service users. EVIDENCE: The ground floor bathroom has been refurbished since the last inspection and has been completed in-house to a very good standard. The handymen employed by the group have been able to use their skills in plumbing and tiling to good effect and the addition of the water feature (an indoor fountain) has contributed to the ambience. Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 Page 13 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 & 30 Service users are supported by staff in sufficient numbers, who are appropriately trained for their work. EVIDENCE: The staffing rota showed that there are sufficient staff on duty across all shifts, day and night, to meet the needs of the current service users. Certain care staff are designated as Seniors; they are responsible for supervising 3 or 4 other care staff and for evaluating care plans each month. Service users said that they felt the care staff were good, very caring and understanding; there was a good rapport observed between service users and the staff assisting them. Staff have access to a very good resource library in the form of Training Indexes, information sheets on a variety of health-related conditions and other topics. The care staff are expected to read at least one each month and sign a record. The records showed that staff were exceeding the home’s expected target and every month were gaining information about a wide range of conditions that they may come across with service users. The Induction Training book was seen, belonging to one of the newer workers. This is a comprehensive range of induction standards, based on the Skills for Care (formerly TOPSS) standards. Certificates were seen for mandatory training, such as COSHH, Moving and Handling and Fire Safety. Both the Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 Page 14 Manager and the Operations Manager are trained as Moving and Handling Facilitators. Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 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): 33, 35, 37 & 38 Service users have opportunities to contribute their views and influence how the home runs. Record keeping, policies and procedures are well organised and reflect the home’s approach to safeguarding the service users. The home strives to improve standards and works alongside the relevant agencies to meet requirements. Some good practice was seen in the way that risk assessments are used in the care plans. EVIDENCE: The organisation that runs the home has the Investors in People award and has its’ own Quality Assurance standards. This includes surveying service users to gain their views. Service users are also involved in the decisionGrange Court DS0000001244.V266381.R01.S.doc Version 5.1 Page 16 making of the home, through their monthly meetings and by individual discussion. The Manager does not handle finances on behalf of service users. For those who cannot manage their own personal allowance, purchases can be made through the petty cash system, for example, payment for hairdressing and trips out, and the organisation invoices the person who pays the care fees. An inspection was made of a range of regulatory and operational records, including care plans, staff rotas, staff training records, fire safety records and accident records. All were kept in the appropriate manner and information appeared to be accurate and up to date; however, the accident record book did not comply with the requirements of the Data Protection Act. This was discussed with the Operations Manager and provider and advice given as to how this could be rectified. There is a thorough approach to health and safety within the home and staff are given the appropriate training and day-to-day support to assist them in a range of tasks; for example, the use of pictures within a moving and handling risk assessment and plan, so that staff are clear about what piece of equipment is needed and how it is used. It was noted that there is health and safety information located around the home for staff to readily access. A Fire Officer’s report, received between the inspection visit and the production of this report, has highlighted areas that the provider needs to address in the long term, and it is noted that the provider has agreed a timescale for this work to take place. Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X 3 X X X X X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X 2 3 Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 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 OP12 Regulation 16(2)(m) & (n) 13(6) Requirement Case files must clearly show how activities are related to personal interests. (Outstanding from previous inspection) All staff must have adult protection training if they and residents are not to be put at risk. Accidents must be recorded in such a way that the Data Protection Act is complied with. Work must be carried out to comply with the requirements of the Fire Officer. Timescale for action 30/06/06 2. OP18 30/06/06 3. 4. OP37 OP38 17 23(4) 30/06/06 10/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Grange Court DS0000001244.V266381.R01.S.doc Version 5.1 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 DS0000001244.V266381.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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