Inspection on 16/08/05 for Heaton Grange

This inspection was carried out on 16th August 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

Heaton Grange 25/01/10

Heaton Grange 23/08/07

Heaton Grange 18/07/06

Heaton Grange 07/02/06

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Heaton Grange 425(a) Toller Lane Heaton Bradford BD9 4NN Lead Inspector Michael Smithson Announced 9.30am. 16 August 2005 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. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Heaton Grange Address 425(a) Toller Lane, Heaton, Bradford, West Yorkshire BD9 4NN 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 494439 Mr Deepak Patel Mrs Susan Miller Care home only 20 Category(ies) of Old age (15), Dementia - over 65 (2), Physical registration, with number disability - over 65 (3) of places Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15 December 2004 Brief Description of the Service: Heaton Grange is a single storey detached residence situated in the Heaton area of Bradford. There are car parking facilities to the front and the home is adjacent to local public transport. The local shop is within walking distance with the home being situated approximately 3 miles from Bradford city centre. There is a patio and garden area with seating for the service users.The living accommodation consists of an open plan lounge and dining area with a conservatory to the front of the home. Bedrooms are both single and double occupancy with bathrooms and toilets all based on one level. Disabled access is via a ramp to the front door. All accommodation is on the ground floor. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first of 2 inspections to be undertaken for this inspection year. The inspection was announced and the next inspection will be unannounced. Service users and visitors were informed that the inspection would take place by providing a poster to display. A number of questionnaires were provided to seek the views of service users and relatives. The inspection focused on any outstanding issues from previous inspections, the records, the environment, and discussions with service users, visitors and staff. The home has very recently changed ownership and the new provider is making plans to make a number of improvements to the environment. These include refurbishment of the bedrooms, the older bathrooms and replacement of the lounge chairs. The exterior of the building was being improved at the time of the inspection. The new provider is making arrangements to replace the old sign. The feedback from service users and visitors was very positive. One visitor had been provided with a bed in his father’s bedroom so he could spend time with him during a serious illness. He was very appreciative of the efforts made by the manager and the staff to provide a good standard of care for his father. What the service does well: Heaton Grange is a small friendly home which meets the needs of the service users. They have a good understanding of the limits of the care they can provide. The staff team has remained stable with very few changes since the last inspection. This allows good consistency or care and familiarity for service users. The palliative care currently being provided is of a good standard. The staff are aware of the needs of both the service user and the relatives. Expert advice has been sought from specialist nursing services. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 6 One service user has been allowed to bring her dog into the home, which has greatly improved her quality of life. The other service users have also enjoyed having the dog around the home. The new provider has a number of plans to improve the facilities offered at the home. When these are completed they will provide more up to date fixtures and fittings and improve the decoration of the home. He also has long term plans to increase the number of single bedrooms and provide some en-suite facilities. What has improved since the last inspection? What they could do better: A format for informing CSCI of official notifications under Regulation 37 must be implemented. A fax machine is available for sending the information. Regulation 26 meetings between the provider and the manager must be formalised. A report must be produced following the monthly meetings and be available for inspection. Advice was given as to the content of the reports. The staff individual supervision sessions must recommence. All staff must be provided with supervision and a record kept. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 7 Updated training must be provided for the staff not wishing to undertake NVQ level 2. This must include, manual handling, basic food hygiene, first aid and health and safety. Updated fire safety training must be provided for all staff. The training must be provided twice a year and a record of attendance kept. The electrical system, together with electrical equipment and water temperature checks must be undertaken and a record kept. 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. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 8 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 Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 9 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 and 4. Information regarding the home is not provided in a suitable format to help service users make an informed choice about the home. However, the service users and relatives are given the opportunity to visit the home prior to admission. The home only admits service users whose needs they can meet. EVIDENCE: The statement of purpose has been completed, however it does not meet the requirements for the service user guide. A separate document must be produced which is a simplified user friendly version of the statement of purpose and must include all the information required in Regulation 5 of the Care Homes Regulations 2001. The pre-admission records for 3 service users were checked. Two of the service users were transfers from another care home and detailed information regarding the service users needs were supplied prior to admission. The third service user was admitted with members of the family, who assisted in the completion of the care plan. Members of family for all the new service users were given the opportunity to visit the home prior to admission. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 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 and 11. The health and personal care needs of service users are recorded and are met. Service users are provided with good quality palliative care. EVIDENCE: The care planning system has much improved. A standard format is available for all service users. Four care plans were seen during the inspection. Individual needs are recorded and are updated. Health care assessments and monitoring are undertaken. The manager and the staff team review the care plans each month. The Care documentation for a service user receiving palliative care was assessed. The record provided up to date information regarding the service user’s deteriorating health and the care now required, however, it was suggested that they consult with the Macmillan Nurses to see if any further information was required. The care plan stated the service user required regular 2 hourly turning and encourage fluids. This needs to be reflected in the records that the turning task has been undertaken and details of the amount of fluids given. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 11 The home has made great efforts to assist the family of the service user receiving palliative care. Arrangements have been made for him to stay at the home while visiting his father. He was currently on a 5 day visit to the home. He was extremely happy with way the manager and the staff were caring for his father and felt confident they could continue to meet his needs. He was aware that the home was being supported by the Macmillan Nursing service and further help and expertise had been arranged if required. The medication system has much improved. A new monitored dosage administration procedure has been implemented. The new system is much better organised and the administration documentation improved. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 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 and 13. A basic range of activities are offered at the home. The service users who are able can make choices in their daily lives. EVIDENCE: A basic range of activities are offered, these usually include listening to music and walks in the garden and local area. Games sessions are organised on the odd occasion. The staff felt they had time to chat with service users in and amongst their daily routines. However there did tend to be more time for activities during the afternoon shift. The manager is keen to keep members of family informed about the care provided. The family are encouraged to help in the production of the care plans. Service users are offered a degree of choice depending on their capacity to make safe decisions. One service user has brought her dog into the home. All the service users appear to have grown very fond of the dog and they enjoy seeing him around the home. The service user who owns the dog is not capable of taking the dog out for a walk so a member of staff undertakes this task. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 13 A newly admitted service user has been bought a budgerigar, which has helped her to settle at the home. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 14 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 and 18. The complaints procedure and adult protection training for staff protects the rights of service users. EVIDENCE: No complaints had been received since the last inspection. The complaints procedure details are recorded in the statement of purpose. A user-friendly version with full contact details for the CSCI must be included in the new service user guide. The local authority No Secrets guidance is available and 8 of the staff have now completed adult protection training. Arrangements are being made for the remaining staff to attend. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 15 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 and 26. The environment is adequate and meets the needs of service users, however it will benefit from the planned refurbishment. EVIDENCE: The environment is maintained to an adequate standard. The new provider has plans to refurbish the building and has made a start on clearing the overgrown areas around the exterior. The bedrooms are maintained to a good standard of hygiene and cleanliness and service users are encouraged to bring in personal possessions and small items of furniture. All the bedrooms are lockable and keys are available. The bedrooms are due for refurbishment in the near future. There are 2 bathrooms and a wheelchair accessible shower room. The older bathrooms are due for refurbishment. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 16 The communal areas were clean and tidy. There is a large lounge/dinning area, a small lounge and a conservatory. The provider has obtained quotes to replace the lounge chairs. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 17 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) 27, 29 and 30. The staff numbers are adequate and the training provided allows service users needs to be met. EVIDENCE: The staff team has remained stable with very few changes since the last inspection. Staff rotas are completed which show 3 staff on duty in a morning, in an evening and 2 waking night staff. The recruitment records for 2 recently employed staff were checked. The records included application forms, references and a completed CRB check. The existing staff have now all completed CRB checks. The home has made good progress with regard to achieving 50 NVQ 2 qualified staff. They have now achieved 60 . A number of the older staff have no wish to undertake NVQ training, however the manager and provider must ensure that basic training is kept up to date, this includes manual handling. First aid, basic food hygiene and fire safety. All the staff on duty were spoken to during the inspection. One member of staff was interviewed in private. The member of staff had completed a wide range of training including; NVQ 2 and adult protection. She showed a good knowledge of the daily routines and the needs of individual service users. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 18 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) 31, 36, 37 and 38. The manager has gained in confidence since undertaking the Registered Managers Award. Both she and the home have benefited. The new provider and the manager are still trying to establish a good working relationship following the recent changes. EVIDENCE: The manager is nearing completion of NVQ level 4 and the Registered Managers Award. She has gained a good degree of confidence and knowledge while completing the course and has implemented a number of new policies, procedures and care practices. The provider has only recently taken over ownership of the home and is still getting used to how the home operates. He visits the home on a very regular basis. However no formal monthly monitoring system as required under Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 19 regulation 26 has been set up. Advice was provided as to the information required to be monitored and recorded. An incident recently occurred at the home which was reportable under Regulation 37 notifications. The incident was not reported to CSCI. The provider and the manager were reminded of their responsibilities to notify CSCI and advice was given regarding a suitable reporting format. Health and safety information is provided and the majority of the required safety checks are completed. However the last fire safety training was undertaken 12 months ago. The manager has consulted with the Fire Service regarding suitable training for staff. Once this has been agreed then all staff must receive fire safety training. The names of the staff attending must be recorded. The manager and the provider were made aware that staff should receive fire safety training twice a year. A range of safety checks are undertaken, however arrangements must be made to complete the water temperature checks and the electrical safety and equipment checks. The manager tries to involve the staff in the decision making process. She has devised a format used for staff supervision, however not all staff have received supervision. This must be addressed. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 20 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 2 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x x x 2 2 2 Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 21 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. 2. 3. 4. 5. Standard OP1 OP31 OP36 OP37 OP37 Regulation Reg 5 Reg 9(2) Reg 18 Reg 37 Reg 26 Requirement A service user guide must be produced. The manager must complete NVQ level 4. All staff must be provided with formal individual supervision. CSCI must be informed of all the notification incidents outlined in Regulation 37. A record must kept of the required monthly meetings between the provider and the manager. Fire safety training for staff must be provided twice a year and a record of attendence kept. Electrical safety checks and water temperature tests must be undertaken. Timescale for action 01/11/05 31/12/05 01/12/05 Immediate Action. Immediate Ation. Immediate Action. 01/12/05 6. 7. OP38 OP38 Reg 23(4)(d) Reg 13(4) 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 OP8 Good Practice Recommendations The manager should consult with the specialist nursing services to determine that the records for the palliative 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 22 Heaton Grange 2. OP30 care are adequate. In particular the recording of fluid balance and bed turning. The staff not undertaking NVQ must be kept up to date with, manual handling, fire safety, first aid and health and safety training. Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 23 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 Heaton Grange 20050815 Heaton Grange An Stage 4 V235780 S64467 J52.doc Version 1.40 Page 24 - 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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