Inspection on 11/10/05 for Hodge Hill Grange

This inspection was carried out on 11th October 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

Hodge Hill Grange 17/04/09

Hodge Hill Grange 23/04/08

Hodge Hill Grange 06/11/07

Hodge Hill Grange 02/06/07

Hodge Hill Grange 06/09/06

Hodge Hill Grange 09/02/06

Hodge Hill Grange 22/03/05

Hodge Hill Grange 03/11/04

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Inspirations

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

CARE HOMES FOR OLDER PEOPLE Hodge Hill Grange 150 Coleshill Road Hodge Hill Birmingham B36 3AD Lead Inspector Kath Strong Announced 11 October 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hodge Hill Grange Address 150 Colsehill Road, Hodge Hill, Birmingham B36 3AD 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) 0121 730 1999 0121 730 1888 Southern Cross Healthcare Care Home 54 Category(ies) of OLd Age (54) registration, with number of places Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Maximum 54 older adults, minimum age 65 years. 2. Care Home with nursing of 51 places, personal care only up to three places. Date of last inspection 22nd March 2005 Brief Description of the Service: Hodge Hill is a purpose built home providing nursing care for up to 51 and residential care for up to three persons of 65years of age or above. The home is also registered to accept residents who may be suffering from dementia. The home is situated on the perimeter of Hodge Hill, within a pleasant suburb, north of Birmingham. The parent company is Southern Cross who own a substantial number of homes across the UK. There are amenities close by including shops and restaurants. There is a regular bus service for access to Birmingham city centre. All accommodation is provided on two floors with a shaft lift for access to them. Bedrooms are single status with en-suite facilities consisting of toilet and wash hand basin. Each floor has two lounge/dining rooms and there is an additional lounge located on the ground floor and a smoking room on the first floor. The large and airy reception area is also frequented by residents. The pleasant garden to the side and rear of the premises is also used by residents. The kitchen and laundry rooms are located in the basement of the building. There is a drive for access to the front of the premises and at the rear sufficient parking for ten vehicles. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct an announced inspection. The outcome was determined by various means. The requirements generated at the last inspection were reviewed in respect of progress. In depth discussions were held with the newly appointed manager. Relevant documentation was examined including four care plans. Case tracking was carried out to determine if the identified needs of residents were being met. Six residents were spoken with independently and a group activity was observed. A visitor was spoken with and two members of staff were formally interviewed. A tour of the premises was also carried out. At the conclusion verbal and written feedback was provide to the manager. What the service does well: What has improved since the last inspection? The main lounge has been re-painted. The ground floor corridor carpets have been replaced. New worktops have been installed in two of the four dining area kitchenettes. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 6 Bedspreads and lounge curtains have been ordered. Five profile and ten divan beds have been ordered as replacements. A programme for decorating the premises has been collated with plans to commence work within the next few weeks. A programme of regular staff supervisory meetings has commenced. There was evidence that the recently appointed manager has had a positive effect on the home and has identified and commenced improvements. 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. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 Prospective residents are supplied with sufficient information for them to make an informed decision about the home. Comprehensive pre-admission assessments are carried out before a placement is offered, which ensures that the home is able to meet all of the identified needs. EVIDENCE: The statement of purpose and service user guide were determined to be satisfactory. The manager advised that the documents are currently being reviewed. Contracts of terms of residency are issued to all residents irrespective of the funding arrangements. The home must ensure that the room occupied is included in the document. The manager, at a venue convenient to the prospective resident carries out pre-admission assessments. The manager advised that following the appointment of a deputy manager, the deputy and a senior sister would also carry out assessments. The care plan generated by social care and health is Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 9 also utilised and reports may be requested from other health care professionals prior to a placement being offered. Prospective residents and their relatives are encouraged to visit the home as often as they wish, unplanned visits are welcomed. They are offered a meal and supported in circulating with residents and staff. Following admission a trial period of four weeks is provided and subsequent review by both parties before a placement is confirmed. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.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, 10 and 11 The care plans for the majority of residents are fragmented and inadequate in meeting resident’s needs. There is ample evidence of the involvement and recommendations of external professionals. The process for the administration of medications does not ensure residents safety. Personal support is offered in such a way as to promote and protect resident’s privacy and dignity. EVIDENCE: The care plans of the two latest admissions were examined and found to be a considerable improvement to the previous system. The home must establish a system for completion of the section concerning visitors. Two care plans established earlier were found to be unacceptable and information was stored in poor sequence making reference to files difficult. Concerns were raised regarding the lack of information in respect of descriptions of pressure sores. Linked with the use of the newly acquired camera, the new system would serve to overcome this problem. The home is strongly advised to complete the implementation of the new system for all residents. Other files relevant to the day-to-day care such as food consumed, fluid charts, elimination, personal hygiene and re-positioning, which are completed by care assistants were found Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 11 to be inadequate. Care staff must make comprehensive and appropriate recordings in the respective files. There was ample evidence of the homes proactive approach to the input of external professionals. The requirements made at the last inspection regarding administration of medications had been fully addressed. The administration practices during lunchtime were observed and a concern was brought to the manager’s attention. When the nurse enters a bedroom all medications must be out of reach of passers by. All medications must be stored in the locked trolley. Care staff were observed using residents preferred term of address and providing friendly advice and support. A good rapport was noted. All personal care is delivered in the privacy of the resident’s bedroom or a bathroom. Very ill residents are offered the option of being admitted to hospital or remaining at the home. The decision is made following negotiations with relatives and external professionals thus ensuring that the residents care needs can be met. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 A varied programme of activities is provided and residents are encouraged to maintain links with the community. Resident’s views are sought and opinions are acted upon. Dietary needs are well catered for, a balanced diet and a selection of choices provides residents with control over what they eat. EVIDENCE: The home has commenced recording the life history and backgrounds of residents including their preferred recreational pursuits. The activities programme is regularly discussed during the residents meetings. The home employs a full time activities co-ordinator who attends the meetings and as a result reviews the programme. The activities provided are varied and interesting. A resident said, “I am very happy with the things we do”. A bingo session took place during the afternoon and a visitor was observed participating. The manager advised that two residents attend a club twice a week. Another resident walks around the perimeter of the building four or five times per day. The activities co-ordinator also arranges for residents to go for walks or shopping. It was noted that staff would carry out shopping on behalf of residents. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 13 The home has a policy of open visiting. A visitor said, “ I come to the home twice a week and have been for three years even though my friend has died”. Meals are served in the lounge/dining rooms or in residents own bedrooms. Lunch was observed being served. Meals were well presented and staff gave discreet assistance. A resident reported, “Food is pretty good”. Another resident informed the inspector that she has egg on toast every morning. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.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 information supplied to residents regarding complaints is not comprehensive in respect of complainant’s options. Staff failed to demonstrate adequate knowledge in respect of their roles and responsibilities in the protection of residents from abuse. EVIDENCE: The homes written complaints procedure must be amended to indicate that a complainant may refer to CSCI at any stage of the complaint. The homes system for dealing with complaints was found to be satisfactory. The written policy regarding adult protection must be amended to indicate that both Social Care and Health and CSCI must be informed and that under no circumstances should the organisations operations manager carry out an investigation. A trained member of staff and a carer were interviewed and both failed to display adequate knowledge of their responsibilities in abuse or suspected abuse. The organisation needs to review the training provided for staff. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.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 and 26 The home provides comfortable, well maintained accommodation within a homely environment. Resident’s bedrooms appear to suit their needs but fail to fully ensure privacy. EVIDENCE: The main reception area is light and airy and provides comfortable seating. Residents are given a choice of communal areas and an attractive secluded garden for use during clement weather. There are two lounge/dining rooms on each floor, a further lounge situated on the ground floor and a smoking room on the first floor. Each lounge/dining room includes a kitchenette with fridge, microwave and drinks making facilities. All areas of the home are very welcoming in appearance. The radiator cover in one of the first floor lounge/dining rooms is in need of repair. Toilets and assisted bathing facilities are strategically located on each floor and all bedrooms have en-suite facilities comprising of toilet and wash hand basin. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 16 Bedrooms were noted to be comfortable and include all furniture required. They were personalised the degree preferred by the occupants including residents own furniture. Bedroom doors have not been fitted with suited locks; this remains an outstanding requirement from the last inspection. All areas of the home were found to be tidy and hygienic including the kitchen and laundry rooms, which are located in the basement. Both rooms were noted to be spacious and very well organised with all practices carried out appropriately. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.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, 28, 29 and 30 The home employs staff in appropriate numbers and skill mix. Staff morale is high impacting on consistency of care. The home has not provided sufficient staff training to enable them to have adequate knowledge and skills to meet the needs of residents. EVIDENCE: The levels of trained and care staff deployed for each shift were determined to be satisfactory. The home employs ancillary staff including administrator, housekeepers, laundry and maintenance personnel as well as an activities coordinator. A vacancy exists for the role of deputy manager, advice was given that the organisation are actively working towards filling the post. The home does not meet the requirement that 50 of care staff have completed NVQ level 2 training but is actively working towards this. The manager also indicated that other training needs have been identified and arrangements are being made to address this issue. All new staff are recruited with all relevant procedures and checks being completed prior to a post being offered. The manager confirmed that gaps found in the files of staff that have been employed for a significant period of time are being addressed. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.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, 32, 35, 36 and 38 The manager is supported by her senior staff in providing clear leadership and lines of accountability throughout the home. Arrangements are in place to promote the health and safety of residents. EVIDENCE: The recently appointed manager has previous relevant experience for her current role. She has completed the registered managers award and is an NVQ assessor. She has furnished CSCI with an application for registered manager status. She displays an open approach, leadership skills and the ability to manage the home. Staff and residents comments regarding the manager were complimentary. The home has appropriate systems in place for the safe keeping and recording of financial transactions of resident’s personal monies. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 19 The manager has established regular formal staff supervisory meetings, which are fully documented. She was advised to obtain the signatures of both parties on each occasion. All relevant servicing of equipment was being carried out in a timely fashion. Fire alarms and emergency lighting are being checked and recorded weekly. Fire exits are also checked regularly. Fire lectures and fire drills were being conducted and fully documented. The manager was currently reviewing and writing risk assessments in respect of the premises. The risk assessment regarding fire was seen to be comprehensive and valid. CCTV equipment monitors the exterior of the home and is not intrusive to residents privacy. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.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 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 3 x x 3 3 x 3 Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.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. Standard OP2 Regulation 5(1)b Requirement The registered person must ensure that contracts of terms of residency include details of the room occupied. The registered person must ensure that details of pressure sores are comprehensive The registered person must ensure that care staff documentation of personal care provided is comprehensive. The registered person must ensure that medications are stored safely at all times. The registered person must amend the complaints procedure to inform that a complainant may contact CSCI at any stage of the complaint. The registered person must amend the adult protection policy in respect of the agencies to be notified and that the adult protection team will carry out the investigation. The registered person must ensure that staff training regarding adult protection is comprehensive. The registered person must make arrangements for the Timescale for action 30/11/05 2. 3. OP7 OP7 15(1) 15(1) 15/11/05 15/11/05 4. 5. OP9 OP16 13(2) 22(2) 17/10/05 30/11/05 6. OP18 13(6) 15/12/05 7. OP18 13(6) 31/12/05 8. OP19 23(2)c 31/10/05 Page 22 Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 9. OP24 16(2)b 10. OP28 18(1)c 11. OP30 18(1)c repair of the radiator cover in a first floor loung/dining room. The registered person must install suited bedroom door locks that may be overridden in an emergency. N.B This remains outstanding from the previous inspection. The registered person must ensure that 50 of care staff have completed NVQ level 2 training. The registered person must complete the already commenced process of ensuring that all staff receive mandatory training. 31/01/06 31/01/06 31/01/06 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 OP7 Good Practice Recommendations The home is recommended to complete the process of transfers of all care plans to the new improved system. Hodge Hill Grange E54 S24855 HodgeHillGrange V245510 111005 AI stage 1.doc Version 1.40 Page 23 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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