Inspection on 16/11/05 for Hatherley Grange Nursing Home

This inspection was carried out on 16th November 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

Hatherley Grange Nursing Home 17/05/07

Hatherley Grange Nursing Home 23/05/05

Hatherley Grange Nursing Home 09/11/04

Hatherley Grange Nursing Home 18/05/04

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

CARE HOMES FOR OLDER PEOPLE Hatherley Grange Nursing Home 26 St Stephen`s Road Cheltenham Glos GL51 3AA Lead Inspector Peter Still Unannounced Inspection 16th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hatherley Grange Nursing Home DS0000016457.V257269.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. Hatherley Grange Nursing Home DS0000016457.V257269.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hatherley Grange Nursing Home Address 26 St Stephen`s Road Cheltenham Glos GL51 3AA 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) 01242 251321 HatherleyGrange@ALMONDSBURYCAREFSBUSIN ESS.CO.UK Almondsbury Care Limited Mrs Sheila Ann Crew Care Home 25 Category(ies) of Dementia - over 65 years of age (25) registration, with number of places Hatherley Grange Nursing Home DS0000016457.V257269.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2005 Brief Description of the Service: This care home specialises in the care of elderly people with dementia, and has 3 places for those under 65 years who have the same illness. It is located on the outskirts of Cheltenham town in a residential area. It is close to local shops and a church. It can offer both single and double bedrooms, situated over 4 floors accessed via a shaft lift or stairs. On the ground floor there is a large lounge, conservatory, and dining room with smaller quiet area. Viewed from the conservatory and accessed via a ramp, is a small but safe patio area. The home has a qualified nurse on duty at all times, with care staff who are experienced in the specialised needs of service users with dementia. Hatherley Grange Nursing Home DS0000016457.V257269.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 9:30 and 12:10. The manager and senior carer supported the inspection. Three relatives were spoken with and four staff and the residents were observed. The atmosphere in the home was relaxed and caring with staff working sensitively, and were attentive to residents needs. Relatives spoke highly of the care provided. A number of records were inspected and there was a tour of the building. What the service does well: What has improved since the last inspection? A sophisticated care planning documentation system has been purchased to aid ease of access to well recorded individual care files. Significant external decoration has been undertaken, which has included many new windows and this work is near completion. The two requirements from the last inspection have been addressed. The last inspection also gave four recommendations and two have been addressed. A recommendation concerning provision of suggestion slips in the reception area along with a box for placing these in has been considered but not felt to be necessary however the home has conducted a further survey as a way of gaining feedback on the running of the home. The responses and action to points made in the previous report demonstrates a positive approach from the provider. Hatherley Grange Nursing Home DS0000016457.V257269.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. Hatherley Grange Nursing Home DS0000016457.V257269.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 Hatherley Grange Nursing Home DS0000016457.V257269.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Residents are protected by good assessment practice. EVIDENCE: Three care files were reviewed, which showed comprehensive pre admission process and that sufficient information is provided. A month’s trial period is provided. New care planning documentation helps to ensure the standard is met. Intermediate care is no longer provided. Hatherley Grange Nursing Home DS0000016457.V257269.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 Good individual care planning is recorded and meets the needs of residents. EVIDENCE: A new individual care planning documentation system has been purchased since the last inspection. The professionally produced system provides easy access to key documentation and the updating of records. Three care files were reviewed and were up to date. The system, whilst simple to refer to, has taken time to implement and this task had nearly been completed for all residents. One relative talked about the way staff work through the problems of residents, indicating that there have been difficulties but these have not left and that staff find a way of understanding residents needs to resolve issues. Files showed that needs were identified and communicated for staff to use. There was evidence of good liaison between the home and professional agencies and the manager should be commended for fostering this. A relative supported the evidence and talked about the way a GP is called whenever there is a concern and that “there is good liaison with local agencies”. Hatherley Grange Nursing Home DS0000016457.V257269.R01.S.doc Version 5.0 Page 10 Hatherley Grange Nursing Home DS0000016457.V257269.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, 15 Residents are supported by staff who have a good understanding of their individual needs. The dietary needs of residents are met. EVIDENCE: Residents were seen mainly in the lounges, where staff were constantly attentive to residents and should be commended for the way they did not pass by without gentle communication and reassurance. Residents appeared to respond by showing contentment. It was clear that staff have taken time to gain understanding of individual needs, with likes and dislikes being known. Three relatives supported the view that high quality care was provided and comments included: Their relative “gets all the TLC we could hope for”; “The food is very good”; when a resident went to hospital in emergency, a member of staff went too to be with the resident; “the home is close knit and homely”; “well pleased and no complaints – nothing but praise and nothing can be improved – I am treated as one of the family by the manager and staff”. The home had needed to use a qualified chef from an agency at the time of the inspection and is seeking a permanent chef in the New Year. The agency chef produced an appealing meal for lunch, of roast beef and Yorkshire pudding, which residents were seen to enjoy. There were fresh vegetables and the menu Hatherley Grange Nursing Home DS0000016457.V257269.R01.S.doc Version 5.0 Page 12 appeared to be varied and nutritious. Special dietary needs are recorded and catered for. The chef was committed to his work at the home and spoke of ensuring continuity until the New Year. It was nice to see that when the chef had completed tasks, he was engaging with residents and staff and able to check that residents were happy with their food. It was also observed that during the lunch time period, staff were very attentive and patient working with residents individually with their meals. Hatherley Grange Nursing Home DS0000016457.V257269.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): Not inspected EVIDENCE: Hatherley Grange Nursing Home DS0000016457.V257269.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, 21, 26 The home is well equipped to meet resident’s needs and completion of work being undertaken or planned will ensure resident safety and comfort. EVIDENCE: The provider employs a person to deal with maintenance. The home has a homely feel to it, but it is not a new, purpose built facility and consequently there will always be small maintenance tasks to be completed. The member of staff was enthusiastic and is a valued member of the staff team. The provider should be commended for ensuring near completion of significant refurbishment works externally to the home and compliance with guidance from the fire officer. The home is being decorated externally and windows are being replaced. It is unfortunate that resolution of one problem has caused another, where the intermittent strips fitted to fire doors has caused some not to close properly. A requirement will be made to complete an audit of fire doors and to ensure they all close effectively. Hatherley Grange Nursing Home DS0000016457.V257269.R01.S.doc Version 5.0 Page 15 The laundry room is difficult for the provider to maintain, due to the lack of available space and structure. It was noted that a window was broken and glass missing and that the sink staff use to wash their hands was obstructed and not easy to reach at the time the inspector looked at the room. It was understood that the provider already has work to the window within a maintenance programme and a recommendation will be made for refurbishment of the laundry to be included within the ongoing future maintenance plan. In relation to infection control, it is important for staff to have easy access to hand washing facilities and a recommendation will be made regarding this. The last inspection gave a recommendation that some small washbasins in resident’s bedrooms be replaced. The provider has considered this and not felt it necessary to put in new washbasins. At this inspection the matter was reviewed and remains of concern. Other bedrooms were also seen to have small washbasins and the recommendation will be repeated. Whilst it is recognised that most residents may not wish to use a washbasin, there is a reduction in choice if the facility is not satisfactory and it is also important for staff to have satisfactory facilities when caring for a resident. Space between the taps and basins was limited. One tap was loose and it was understood that this and another vanity unit are to be replaced. The home was clean and hygienic and the staff team should be commended for their hard work to ensure there was no unpleasant odour found anywhere in the home. The kitchen was also clean and organised at a time when the main meal of the day was being prepared. Hatherley Grange Nursing Home DS0000016457.V257269.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): 27, 28 Resident’s benefit from continuity of staff, who have different skills and training to bring to the home. EVIDENCE: Three staff are due to commence NVQ training in January, which will leave three staff who do not hold the NVQ level 2 award. One member of staff was due to commence the assessor’s qualification and this will support the manager who is an NVQ assessor. The Lead carer had completed the NVQ level 2 and 3 and has applied to undertake the level 4 course. It was positive to note that the current staff team are established at the home and provide good continuity. A qualified nurse is always on duty. The manager would have completed the registered managers award by this inspection, however there has been a lack of external assessors, which has meant a delay. The manager hopes completion will be by the New Year. Three relatives spoke highly of the care provided by staff and the manager. Hatherley Grange Nursing Home DS0000016457.V257269.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): 33 The home provides a good caring environment for residents, with effective leadership from the manager. EVIDENCE: The manager said she feels supported by the provider and the manager herself, was considered to provide a caring and committed style of management, which has ensured a happy team of staff and good supportive relationships with external agencies. Staff were seen to be working continually during the inspection and to be fully focused on residents needs. The last inspection made a recommendation that suggestion slips could be provided for relatives and others to complete and put in a box. This was a helpful idea and a valuable way of seeking feedback on the service provided. However the provider has not considered this to be necessary and a further survey of relatives was conducted in June of this year instead. Quality Hatherley Grange Nursing Home DS0000016457.V257269.R01.S.doc Version 5.0 Page 18 assurance is a key task for care homes and it is likely that a future inspection will revisit the quality monitoring system for this home. Unfortunately the outcome of the survey was not at the home to be reviewed on this occasion. Hatherley Grange Nursing Home DS0000016457.V257269.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X Hatherley Grange Nursing Home DS0000016457.V257269.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 Standard OP19 Regulation 23 Requirement Complete an audit of all fire doors and take steps to ensure fire doors close effectively. Timescale for action 03/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP21 Good Practice Recommendations Provided washbasins in residents bedrooms that are large enough to meet their and staff needs. Provided larger washbasins for the two units about to be replaced and replace the other small ones as part of the maintenance programme. Enable staff to have easy access to hand washing facilities in the laundry at all times. Place the refurbishment of the laundry onto the maintenance programme for the home. 2 3 OP19 OP19 Hatherley Grange Nursing Home DS0000016457.V257269.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Hatherley Grange Nursing Home DS0000016457.V257269.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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