Inspection on 08/09/05 for Grange Court

This inspection was carried out on 8th September 2005.

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

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

Other inspections for this house

Grange Court 05/03/09

Grange Court 25/03/08

Grange Court 04/09/07

Grange Court 09/08/06

Grange Court 28/02/06

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 BD17 6HS Lead Inspector Hebrew Rawlins Unannounced 8 & 9 September 2005 th th 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 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 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Grange Court Address Station Road Baildon Shipley BD17 6HS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 531222 01274 531222 Mr Ronald Berry Miss Belinda Igo Care Home Only 30 Category(ies) of Old age (30) Dementia Over 65 (10) Mental registration, with number Disorder (1) of places Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 02/03/05 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. It does 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 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 8th and 9th September 2005 by one inspector. The purpose of the inspection was to ensure the home continues to provide a good standard of care for its residents. The Registered Manager was on duty and made her self available throughout the inspection. Service users and staff present at the visit were made aware of the inspection through discussion with the inspector. They were invited to give their views on the care and services provided. Records were inspected and these included residents care plans and policy documents. What the service does well: What has improved since the last inspection? On this occasion no unpleasant odour was noted in any area and the home was generally found to be more clean and well-maintained. Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 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 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 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 standard(s) 1,2,3,5. Generally the admission process is effective, in particular residents and their families receive relevant information and support. However there was evidence that all residents had not received a copy of the terms and conditions. In addition to this the recorded information on the assessments of residents was fairly basic and did not identify the resources the home will provide to ensure they would meet each person’s range of needs, inclusive of social and physical care. EVIDENCE: The home has a brochure, which includes an insert with more specific information about Grange Court. The Terms and Conditions of occupancy was said by the area manager to be in all residents’ rooms. This was found not to be the case whilst visiting residents in their own room. It was said a signed copy of the agreement by a representative of each resident is held in the administrative office off site and therefore could not be inspected. Assessments of each resident are conducted by the home. However the information recorded is fairly basic and is not always signed and dated. The care plans did not specify the resources the home provides to show they could meet each person’s range of needs. There was no recording of the outcome of any pre admission visits within the care plan and this should be included within Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 9 the admission process. For example, in most of the care plans the individual resident’s life history details were not recorded. It was therefore difficult to link activities with which the resident is involved to the home’s capacity to maximize that resident’s independence. Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 10 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 standard(s) 7,8,9,11. Further developments are still needed, to ensure consistency and continuity of information in care plans so that needs of residents are not overlooked. Not all personal files have been updated to include spiritual needs and dying wishes. Medication sheets were up to date. EVIDENCE: The care plans were variable and did not include the details of individual resident’s personal preferences such as appearance, getting up and going to bed times, favourite types of music. There was no specific guidance for staff on how to approach a person exhibiting challenging behaviour. Care plans were written from the perspective of what the person could not do, rather than what they could still do and the ways in which staff might continue to help them to maintain skills. Not all residents’ files have been updated to include spiritual needs and death wishes. Looking at the medication sheet it was noticed the administration procedure policy is being followed. It was pleasing to note that care staff write in the daily logs but in order to improve the quality and relevance of the information recorded this should be monitored as part of the process of staff supervision. Daily records made generalised repetitive comments which did not make reference to the care plan Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 11 therefore it was not clear how key-workers gathered the information to write a progress diary. One for example described a person becoming more unsettled with more incidents but this was not followed by an action plan. Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 12 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 standard(s) 12,13,15. It was not clear from the case files how activities in which residents were included were related to personal interests. This said, it was evident that staff encouraged residents to participate in social and leisure activities as well as maintain links with their friends and family. EVIDENCE: The limited background history in some files must make it difficult for staff to initiate conversation. It was not clear from the care files how activities were related to personal interests. The menu showed the choice of meals for the day. Staff were reminding people what they had chosen. The staff were pleasant and encouraging and assisted those people who needed feeding in an appropriate manner. Visitors to the home said they were made welcome and were kept up to date with any changes in their relative’s wellbeing. However they were expressed concerns about the lack of activities within the home. Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 13 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 standard(s) 16,18. The home provides clear information on how to make a complaint about the service. It includes reference to the Commission for Social Care Inspection if people want to take a complaint outside the home. Staff had an understanding of adult protection but all staff must have adult protection training if they and residents are not to be at risk. EVIDENCE: Talking to staff, they are all clear on their responsibility about reporting any allegations of abuse. However there are some staff that have not yet had adult protection training. Visitors spoken with were confident that any concerns/ complaint would be dealt with fairly. One resident said she had made a complaint which she had recorded on a loose sheet of paper. The Manager when asked, said there had been no recent complaints and was not aware of the complaint until I brought it to her attention. Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 14 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 standard(s) 19,20,21,23,24,25,26. The home offers a satisfactory standard of safety and physical comfort for its residents. It is decorated and furnished to a good standard with resident able to access the garden areas easily if they so choose. EVIDENCE: Residents are encouraged to bring their own possessions with them on admission and their bedrooms are comfortably furnished. The rooms appear to offer adequate space to ensure residents are comfortably accommodated. Staff were seen to knock on doors before entering. The home is decorated and furnished to a good standard throughout and the communal rooms offer a safe and homely space for the residents. All areas of the home were clean and tidy. Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 Recording of the recruitment practice is not satisfactory and as such comment cannot be made with regard to the suitability of persons being employed at the home. Residents stated staff treated them with respect and are caring. EVIDENCE: Several staff files were looked at. The files of the two most recently appointed staff members showed a completed application form, however, a record of the interview was not available nor who was present during the interview. There was no date of when employment commenced and there was no contract and job description available. In discussion with residents one resident stated that in the home “some staff are kind and helpful, they treat people with respect, and are caring and friendly”. Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The above standards will be inspected at the next inspection. EVIDENCE: Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x x x Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 18 yes Are there any outstanding requirements from the last inspection? 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 2 Regulation 5 Requirement All residents should receive a copy of the terms and condition.(raised at previous inspection) Assessment information should specify the resources the home provides to show they are able to meet each person’s range of social care and physical needs . Further developments are still needed, to ensure consistency and continuity of information in care plans so that needs of residents are not overlooked. Personal files must be updated to include spiritual needs and death wishes.(raised at previous inspection) Case files must clearly show how activities are related to personal interests. All staff must have adult protection training if they and residents are not to be put at risk. Recording of recruitment procedure is not satisfactory, which could result in unsuitable persons being employed at the home 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Timescale for action 28/11/05 2. 3 14 28/11/05 3. 7 15 28/11/05 4. 11 12 28/11/05 5. 6. 12 18 16 13 28/11/05 1/4/06 7. 29 19 28/11/05 8. Grange Court Version 1.40 Page 19 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 Good Practice Recommendations Grange Court 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 20 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 20050908 Grange Court UN Stage 4 S1244 V245167 J52.doc Version 1.40 Page 21 - 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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