Inspection on 07/12/05 for Grangewood Lodge

This inspection was carried out on 7th December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Grangewood Lodge 16/08/06

Grangewood Lodge 07/07/05

Grangewood Lodge 07/12/04

Grangewood Lodge 06/07/04

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

CARE HOMES FOR OLDER PEOPLE Grangewood Lodge Netherseal Swadlincote Derbyshire DE12 8BH Lead Inspector Claire Williams Unannounced Inspection 7th December 2005 09:00 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 Grangewood Lodge DS0000019996.V271137.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. Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grangewood Lodge Address Netherseal Swadlincote Derbyshire DE12 8BH 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) (01827) 373577 Mr John Frederick Fisher Ms Amanda Fay Hatfield Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Plus three (3) day care place not regulated by Commission for Social Care Inspection. 7th July 2005 Date of last inspection Brief Description of the Service: Grangewood Lodge is a Care Home registered to provide Personal care and Accommodation for up to 30 people in the category of older persons. Grangewood Lodge is located near to the village of Netherseal. Grangewood Lodge has extensive grounds, a patio area, and a care park area. Grangewood Lodge has 26 single rooms; of these 17 have en-suite facilities, and 2 double rooms, with en-suite facilities. A variety of lounge and dinning space is provided. There are sufficient bathing facilities to meet the needs of the service user group; the Registered Provide is currently changing the function of the bathroom areas and upgrading them by removing the baths and installing showers. Service users accommodation is located on the ground and first floor of the building, and there is a stair lift for access. The Registered Person is currently working on a rolling programme in order to upgrade certain areas of the home. On the day of inspection there was 24 Residents living at the home. Grangewood Lodge DS0000019996.V271137.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 commenced at 9am. The visit lasted 6 hours. The inspector checked the previous requirements and recommendations made in the previous inspection report, and checked the key areas that were required to be assessed in a 12-month period. She examined care files and associated documents, medication, and training was discussed. The inspector joined the residents for their lunchtime meal and a full tour of the building was undertaken. Time was spent observing residents and staff interaction, and the inspector spoke with 10 residents and 3 staff members. The Registered Manager assisted the inspector with the inspection. For the purpose of this report the people who live in this home will be refereed to as ‘Residents’. What the service does well: The residents spoke very positively about the quality of the care they receive from the staff team and the Registered Provider. Residents felt that the staff team “are very helpful” and one resident stated that the home “was good”. Another resident stated, “”the care provided is second to none”. The residents also spoke positively about the Registered Manager and the way she continues to manage the home well and provides clear and effective leadership to the staff team. The staff team commented that they continue to feel supported by the Registered Manager and felt that they had “really good training opportunities at the home”. The residents continue to have access to a variety of activities both within and outside the home. The activities co-ordinator visits the home 3 mornings a week and facilitates a range of activities including craftwork. The activities coordinator has assisted the residents to provide the provision of a remembrance tree enabling residents to hang a star in remembrance of their loved ones. The staff team are motivated and committed to their roles. The residents are now involved in the development of their care plan, and are regularly consulted about the plan to ensure that any changes in their needs are recorded. The residents live in a safe environment, as the Registered Manager ensures that all aspects of health and safety are addressed, reviewed and records maintained. Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Grangewood Lodge DS0000019996.V271137.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 Grangewood Lodge DS0000019996.V271137.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): These standards were not assessed on this occasion as they were assessed on the previous inspection visit. EVIDENCE: Grangewood Lodge DS0000019996.V271137.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, 8, and 9 The staff team have a good understanding of the residents support needs. This is evident from the positive relationships, which have been formed between the staff and the residents. EVIDENCE: The inspector examined three care plans to ensure that the requirements made in the previous inspection report had been addressed. One of these plans was for an individual that visited the home for an emergency admission. All three care plans were completed in full, covered aspects of the resident’s health, personal and social care needs, and were up to date. The plans contained sufficient information to enable the staff team to meet the resident’s needs. The required risk assessments were completed in full in all files examined. There was evidence that the files for the permanent residents had been reviewed on a regular basis with the involvement of that individual. The inspector examined the case notes recording residents well being. Although the notes were completed regularly for some residents the inspector noted that some residents had long gaps in between the records being completed, which mean that there is insufficient information of the support given to these individuals. Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 Page 10 The inspector spoke with several residents during the inspection and residents spoke very positively about living in this home and the quality of care they receive. Residents comments included; the staff are “friendly and caring”, “the home is the best ever” “the services are good”, “the staff always treat us with dignity and respect, “everything is great here”. The inspector examined the medication practices at the home. Policies and procedures were in place, and the staff members that administer medication have undertaken appropriate training and had a medication competency assessment completed. The medication was generally well managed. The temperature of the medication fridge was recorded on a daily basis. Grangewood Lodge DS0000019996.V271137.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 Social activities are well managed, creative, and provide daily variation and interest for people living in the home. EVIDENCE: An activities co-ordinator visits the home three times a week and facilitates a variety of internal and external activities. An activities file has been developed which identifies the activities provided for the year. The residents made positive comments about the provision of activities and the variety of outings and functions that have been organised recently. The residents have a remembrance tree, so that they can place a star for loved ones at Christmas. Some of the residents are due to attend the Christmas pantomime and the home has had the local Sunday school children visit and sing Christmas carols. The residents felt that the activities provided are in accordance with their interests and preferences. On the day of the inspection the inspector observed the residents play bingo and attend a religious service facilitated by the local church within the home. Grangewood Lodge DS0000019996.V271137.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, 17 and 18 The home has an effective complaints and adult protection procedures, in order to safeguard residents. Resident’s legal rights are protected. EVIDENCE: The home has a complaints procedure and recording system in place. The inspector examined the records and 2 complaints have been received since the previous inspection. One of these complaints was still active at the time of the inspection. The records confirmed that the complaints have been responded to appropriately. The residents spoken with were aware of the procedure and informed the inspector that they would not hesitate to raise any concerns they had with the staff or the manager. Resident’s legal rights are protected within the home, and they are encouraged to exercise their political views through the provision of postal votes. The home has a Vulnerable Adults policy in place that links in with the Derbyshire Vulnerable adult’s procedures. Majority of the staff team have undertaken some form of abuse training either internally or through their NVQ training, but there are some staff members who still require training in this area. The Registered Manager informed the inspector that there have been no incidents at the home this year. Grangewood Lodge DS0000019996.V271137.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): 19, 20, 21, 22, 23, 24, 25, 26 The home is furnished and maintained to a satisfactory standard and offers homely and spacious facilities for residents to enjoy. EVIDENCE: The inspector undertook a full tour of the environment. All areas of the home are decorated to a satisfactory standard and were free from any odours. The Registered Provider has a redecoration and renewal programme in place. This programme is ongoing and each year certain areas of the home are redecorated or refurbished. The Responsible Provider is fitting privacy locks to bedrooms and bathrooms on a rolling programme and replacing the Fire doors. The Responsible Provider is currently making some internal changes to the bathrooms and is replacing the bath in one room for a shower. The Responsible Provider is planning to replace the kitchen in the near future in response to the previous environmental Health Report. The inspector was invited to view some of the bedrooms by the residents. All bedrooms were personalised with resident’s own belongings, and had the appropriate fixtures and fittings available. Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 Page 14 All communal and bathroom areas were well maintained apart from one area that was soiled but was cleaned as soon as the inspector brought this to the seniors attention. Equipment was available in some of the bathrooms in order to assist with personal care in accordance with residents support needs Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 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 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 Staff morale is high resulting in an enthusiastic workforce that works positively with residents ensuring they have a good quality of life. Recruitment procedures need further improvements in order to fully safeguard residents. EVIDENCE: The inspector examined three staff recruitment and training files. The files contained majority of the required information, however in one file there was insufficient information in relation to their employment history recorded on the application form. There was evidence in the file to confirm that the staff team have access to supervision with a senior. The Registered Manager informed the inspector of the dates that the staff team have attended the mandatory training. All of this training is up to date apart from the training already mentioned on Abuse and Vulnerable adults. Residents spoke very positively about the staff team and the standard of care they provide. The residents felt that the staff team are well trained as they deliver good quality care. The residents confirmed that there are always adequate staff members on duty and that they meet their support needs. Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 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 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 Registered Manager is supported well by the senior staff in providing leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The Registered Manager is experienced, competent and provides clear leadership and has good management skills. The inspector received positive feedback from both residents and staff on how supportive and approachable the Registered Manager is. She ensures that the home is managed in accordance with the best interests of the residents. The inspector checked the financial records and the money held in safekeeping for five residents. All of the resident’s money was stored separately in individual purses. All money held cross-referenced to the balance recorded on the transaction sheets. Receipts are obtained for purchases made on behalf of Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 Page 17 the residents, and two staff members countersign, majority of the transactions made. The inspector was informed that a resident consultation questionnaire was distributed in Sept 2005 and feedback obtained. The Responsible Provider intends to write a report of the findings. Residents have access to regular meeting to discuss issues relating to living in the home. The Registered Manager continues to undertake audit check of the systems within the home. The inspector checked some of the health and safety systems in place at the home. All of the staff team had received updated Fire training. The gas and electrical installation certificates were up to date. The checks on the water temperatures and checks required to prevent legionella were up to date. The electrical appliances were PAT tested in June 2005. Regular checks have been undertaken on all Fire equipment, lighting and all Fire points. The employee liability insurance was in date. Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 2 3 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No 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 (2) Requirement The Registered Persons must ensure that case records of resident’s well being are completed on a regular basis to reflect the support provided. The Registered Persons must ensure that all staff has received training in safeguarding residents from abuse. The Registered Persons must ensure that fitting privacy locks to bathroom and toilet areas is priority within the renewal programme. The Registered Persons must ensure that full history is obtained from all new employees and any gaps are explained. Timescale for action 01/02/06 2. OP18 13 (6) 01/04/06 3. OP21 23 (2) (e) 01/04/06 4. OP29 19 (i) 01/02/06 Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 Page 20 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. 2 3 Refer to Standard OP7 OP8 OP36 Good Practice Recommendations The staff team should ensure that all paperwork is signed and dated in resident’s files. The Registered Persons should consider purchasing chair scales to enable all service users to be weighed regularly. The senior staff should ensure that supervision records are dated. Grangewood Lodge DS0000019996.V271137.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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