Inspection on 23/11/05 for Grange Crescent

This inspection was carried out on 23rd 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 Crescent 17/07/07

Grange Crescent 27/07/06

Grange Crescent 24/05/05

Grange Crescent 30/11/04

Grange Crescent 21/07/04

Grange Crescent 18/02/04

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

CARE HOMES FOR OLDER PEOPLE Grange Crescent 47 Grange Crescent Sheffield South Yorkshire S11 8AY Lead Inspector Janice Griffin Unannounced Inspection 23rd November 2005 09:45a 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 Crescent DS0000002963.V261635.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 Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grange Crescent Address 47 Grange Crescent Sheffield South Yorkshire S11 8AY 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) 0114 255 5539 0114 250 6863 South Yorkshire Housing Association Mrs Dawn Tina Martin Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: Grange Crescent is a purpose built 42-bed home for older people accommodated on four wings. Three of the wings have ten bedrooms, and the fourth has twelve. The four wings are on two floors and each has a lounge, dining area, kitchen and each bedroom has an en-suite toilet and shower. The home is in a residential area of Sheffield with good access to public services and amenities, (e.g. bus service, shops, libraries etc). South Yorkshire Housing Association is the Registered Provider; they work in partnership with Sheffcare Limited, who provides the staff at the home. Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over four hours from 9:45am to 13:40pm. Opportunity was taken to make a partial inspection of the home and examine a selection of records. As part of the inspection process fourteen-service users and three staff, including the manager on duty were spoken to. The manager stated that there was a programme for the regular servicing and maintenance of gas and electrical appliances. No fire exits were blocked and hazardous substances were securely stored, maintaining service users safety. Time was spent talking with small groups of service users and individually with six service users. The inspector was pleased to note that throughout the inspection staff interacted positively and sensitively with each service user who were obviously comfortable and at ease in the company of staff. The inspector would like to thank service users, the manager and staff for their commitment to the inspection process. What the service does well: What has improved since the last inspection? Two of the small kitchens have been refurbished and the damaged furniture replaced/repaired. All the fire doors were closing on their rebates and hazardous substances were securely stored. Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Grange Crescent DS0000002963.V261635.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 Crescent DS0000002963.V261635.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): 1,2,3,4 and 5. A detailed service user guide and statement of purpose had been produced and these clearly provided service users with the necessary information regarding the services and facilities provided by the home. Not all service users individual needs had been fully assessed prior to their admission. Service users were able to have informal introductory visits to the home and at the time of their admission and had been provided with a contract containing the relevant information. EVIDENCE: The statement of purpose and service user guide contained all of the information. Detailed full needs assessments had been completed by referring social worker for some service users admitted to the home, file checked did not have a full needs assessment. Families had been in some service users assessment process as appropriate. required the but one involved Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 9 The manager confirmed that service users were only admitted to the home once they were sure that they could meet their needs. Service users were able to visit the home for informal visits prior to their admission if they wished. Service users confirmed that this helped them to get to know everyone at the home, which made them feel less anxious. Records checked confirmed that service users families had been involved in decisions regarding the arrangements. An up to date contract/statement of terms and conditions had been provided to service users and signed copies were retained on individual files. These clearly detailed the fees, including any extra charges, and the services and facilities provided by the home Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 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 the following standard(s): 8,9 and 11. The service users said that the staff promoted their privacy and dignity and that their health care needs were met, they also said they received visits from health care professionals, including dental and optical treatment. Some service users weight was not been checked on a regular basis. Service user, where appropriate, can take responsibility for their own medication but were not always protected by the homes policies and procedures for recording of medication. The home had a policy for caring for service users at the time of death. EVIDENCE: Three service users plans of care were checked. Each set out individual service users needs and the action required and taken by staff to ensure those needs were met. Discussion with service users identified that a range of health professionals visited the home to assist in maintaining health care needs. Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 11 One-service users daily recordings showed that his/her weight had not been checked for several months. This does not protect the well being of service users. Service users who were able could retain control of their own medication, a lockable facility was provided to store such items. This allows service users to have control over their own medication. Records were kept of medication received, and disposed of. Some medication recording charts had not been signed on some occasions to show whether medication had been given or not. This does not ensure the safe administration of medicines. A pharmacist had checked the home’s medication systems at regular intervals. The care plans contained information about the service users preferences at the time of their death. The home had a policy on death and dying, which assured the service users that at the time of death staff would treat them, their family and friends with care sensitivity and respect. This was reassuring to relatives and service users. Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 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 the following standard(s): These standards were not checked at this inspection they were checked at the last one. EVIDENCE: Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 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 the following standard(s): 17. The service users legal rights were protected. EVIDENCE: The manager said that four-service user had their legal rights protected by the court of protection. She also said that if any other service users requested access to advocacy services then she would facilitate the service for them, if requested. The homes accounts had been audited. Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 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 the following standard(s): 19,24,25 and 26. The location and layout of the home is suitable for its stated purpose. Service users bedrooms met individual’s needs in a comfortable and homely way. The home was comfortable and had a homely atmosphere. Handles were missing on the cabinet doors in one of the small kitchens. EVIDENCE: The home was very clean, with no unpleasant odours noticeable. All the service users said their rooms were well maintained and kept clean. Since the last inspection two kitchens have been refurbished. This has markedly improved the environment at the home. One kitchen still had damaged doors. Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 15 Three bedrooms were checked in detail and many others seen, all were comfortable and homely. Service users spoken to said they were satisfied with their bedrooms, which they were able to personalise this they said made their rooms comfortable and homely. The home had an appropriate amount of sitting, recreational and dining space and there were sufficient rooms for a variety of activities to take place. Outdoor space and all areas of the home were accessible to people in wheelchairs. The string light cords, in some bathrooms and toilets were sticky and dirty, this is not hygienic. Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 16 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): 29. The service users said they felt safe and that the staff were competent and knowledgeable. The recruitment procedures were sufficiently robust enough to protect the welfare of service users. EVIDENCE: Service users said that staff were always there to help them and they felt safe. Three staff files were checked; the files did demonstrate a thorough recruitment process had been followed as required by the regulations. CRB checks had been done and two references obtained, no gaps were noted in staff’s employment history. The homes induction programme met required standard and staff spoken to said it covered such things as safe working practices, the organisation and workers role and the needs of the service user group. This ensures that the service users are in safe hands at all times. Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 17 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. Service users benefited from a home that is well run by the registered manager. Service user surveys had been completed and service users had regular opportunities to discuss and feedback their views of the service provided by the home. Records were in the main up to date and well organised. The homes policies and procedures met the required standards. EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. The staff and service users said that she was committed to ensuring that the home maintains and develops high standards of care, she had completed regular internal audits on all aspects of the service provided by the home. Service users confirmed that they could see the manager when they wished and they said that he was very approachable and supportive. Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 18 Records were securely stored as required and those checked were accurate and up to date and in good order. Staff and service users confirmed that they had access to the appropriate records as required. A representative from the organisation was visiting the home on a regular basis and talking to service users, a report was written following the visit. This allows the provider to ensure that the home is run in the best interest of the service users. There was a quality assurance system, which sought the views of service users. Service user meetings took place regularly both at the home and at other Sheffcare venues. Service users said this made them feel involved in the running of the home and that they could influence the quality of the care offered. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, food safety and infection control. The manager stated that there was a programme for the regular servicing and maintenance of gas appliances. No fire exits were blocked and hazardous substances were securely stored, maintaining service users safety. Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 19 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 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 1 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 2 X X X X 3 3 2 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 20 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 2. Standard OP3 OP9 Regulation 14 13 Requirement Service users must only be admitted to the home on the basis of a full needs assessment. Medication record charts must be signed to show whether medication has been given or not. Service users must be weighed at regular intervals. The damaged kitchen units must be repaired/replaced. The string lighting pull cords need replacing. Timescale for action 01/03/06 23/11/05 3. 4. 5. OP8 OP19 OP26 12 16 16 01/01/06 01/05/06 01/02/06 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 OP28 Good Practice Recommendations By 2005 a minimum of 50 of the care staff must be trained to NVQ level 2. Grange Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Crescent DS0000002963.V261635.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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