Inspection on 28/09/05 for Kidsley Grange

This inspection was carried out on 28th September 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

Kidsley Grange 18/07/07

Kidsley Grange 17/07/06

Kidsley Grange 30/01/06

Kidsley Grange 12/11/04

Kidsley Grange 20/05/04

Similar services:

Carlton Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Kidsley Grange 160 Heanor Road Ilkeston Derby DE7 6DY Lead Inspector Bridgette Hill Unannounced Inspection 28th September 2005 09:10 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 Kidsley Grange DS0000002107.V254850.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. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kidsley Grange Address 160 Heanor Road Ilkeston Derby DE7 6DY 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) 01773 769807 Ashmere Care Group Mr Gerald Poxton, Mrs Sandra R Poxton, Mrs Ann Theresa Poxton, Dr Michael G Poxton, Mr David A Poxton Cheryl Patricia Martin Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 2 day care places The Manager completes the Registered Managers Award (NVQ Level 4 in Management) by September 2005 12th November 2004 Date of last inspection Brief Description of the Service: This Care home situated in the village of Smalley. The home is a converted building on two floors. There are two lounges one incorporating a conservatory and an open plan dining room. There is provision for nursing care to a maximum of 33 service users. The home is located on an acute bend on the A608 road. The access to the car park and the main entrance is via a right turn off Adale road. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Kidsley Grange is registered as a care home offering nursing care and has 33 places. This inspection was an unannounced one which took place over 5 hours. The Manger Cheryl martin was on duty at the time of the visit. During the inspection and 3 residents and were spoken with. Not all residents were able to meaningfully communicate a view of the home. One visiting GP was also spoken with during the visit. Various records including care planning records were examined the findings are recorded in the body of this report. What the service does well: What has improved since the last inspection? What they could do better: The timescale for implementing a regular supervision schedule for all staff has not been met and needs to be implemented. There are improvements to be made to ensure staff are fully conversant and have access to clear procedures regarding the handling of any abuse allegations. Timescales for a number of previous requirement have not been met these must be addressed. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 6 A condition of registration that the registered manager achieves a NVQ (National Vocational Qualification) level 4 or equivalent in Management has also not been met by the timescale of 30/09/05. It is acknowledged at this time that this is progressing. 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. Kidsley Grange DS0000002107.V254850.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 Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 It is considered that residents were given access to information about the home and were appropriately assessed prior to being accepted for admission. EVIDENCE: A Statement of purpose and Service User Guide were available and service users had a copy of these placed in their bedrooms. This meets a previous requirement. These met required standards apart from service user comments not being included in the Service User Guide. The Manager was currently undertaking a service user/relative survey. Records and discussion with the Manager confirmed that pre admission visits to residents were completed and trial visits were offered. One resident spoken with said that their family had chosen the home for them but they were happy with the choice. The home does not offer intermediate care as defined by National Minimum Standard 6. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 9 The registration certificate displayed was not up to date and the replacement certificate issued on 8th March 2005 was not available. A new certificate will be issued. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 The arrangements for the provision of healthcare needs were established. The format for recording assessed care needs should be improved to ensure information is readily available in a format where all related care delivery instructions are recorded alongside assessed needs. EVIDENCE: Samples of two residents care files were examined. These contained photographs of residents and had entries of progress recorded for each shift. Care plans were in place for each resident. Care plans were recorded in a lengthy format which was not based totally on assessed needs. For example a plan was available for ‘technical aids’ these should be part on an agreed plan of care as a response to an assessed need not recorded as a separate individual assessed need. Therefore any equipment for example pressure relieving equipment should be part of the care delivery plan following an assessed need being assistance to maintain tissue viability. This system of recording led to a fragmented description of how care was to be delivered as aspects of related care needs were identified in a number of different ‘care plans’. Little was typically recorded on each page and the care plan was a bulky document with many pages some information being repetitively recorded. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 11 Each plan of care was positively supported by a risk assessment. The content of care plans could also be improved to record more of the residents personal preferences/daily routines. A range of risk assessment trigger tools was being utilised and these and the plan of care were being reviewed on a monthly basis. An audit form was available for the Manager to complete to ensure that files were being maintained. Where residents had been visited by healthcare professionals such as GP’s this was recorded. There were established links in place to ensure residents were offered the services of chiropodists, dentists and opticians. One visiting GP was spoken to during the visit. They expressed the view that staff at the home contacted the GP appropriately and were ‘savvy’ and had good knowledge of the resident. They also said that they felt the staff team communicated well between each other. They said that staff always communicated well with the resident and protected the residents dignity and privacy during examinations. One file examined contained the residents post death wishes but two did not. This is an outstanding requirement from previous inspections that has not yet fully been met. A visit from the supplying pharmacist was being completed on the day of the inspection and the storage and administration of medicines was not inspected at this visit. The previous requirement relating to medication administration records being signed, verified and countersigned by a second staff member was checked and the requirement met. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Whilst a range of activities are offered to service users records are not available to demonstrate that these are part of an agreed plan of care based on individual need. EVIDENCE: Little was recorded in individual care plans regarding the individual social needs and activities participated in by each resident. A book was held centrally recording what activities had taken place and which residents had participated. This gave first names only and it was difficult to establish if the social/leisure activities offered met the residents needs. One outing to Belper Gardens had taken place. Residents in the home appeared to a wide range of abilities when it came to being able to actively participate in leisure activities. Residents religious needs were met by a monthly communion service held in the home and a service also held on a monthly basis. A hairdresser was available in the home each Tuesday to do residents hair. An external entertainer visited the home approximately 6 weekly to do a Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 13 music/sing along session with residents. Movement to music was also held fortnightly. It was evident from the visitors book that a number of people visited the home. Visiting times were displayed on the door. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 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 the following standard(s): 16,18 Staff training and procedures in Protection of vulnerable adults require work to ensure staff are consistent and knowledgeable about the action to be taken following any allegations of abuse being made. EVIDENCE: A complaints procedure was on display and included in the Statement of purpose. This gave timescales for the resolution of complaints and the address of the Commission for Social Care Inspection. A record of complaints was held. Written responses to complainants were sent although one of these was not within a 28 timescale, no reason for the delay in responding was recorded or sent to the complainant. One resident spoken with said they were not sure how to make a complaint but said they felt able to approach the Manager if they had concerns. It was planned that the Manager of the home completes Protection of vulnerable adults training in October 2005 and would then cascade this training to staff. This is an outstanding requirement from previous inspections. There was information available in the home on Derbyshire County Councils Protection of vulnerable adults procedures which the Provider agrees to when accepting residents funded by the Local Authority. The procedure in the home advocated internal investigation which is not in accordance with locally agreed procedures. This has been highlighted previously and is an outstanding requirement from previous inspections. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 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 the following standard(s): 20 The communal are of the home were comfortable homely and suitable to meet the needs of the residents. EVIDENCE: At this visit only the communal lounges and dining room were inspected. The removal of a wall to make a large lounge incorporating a previously little used conservatory had improved the amount of communal space being regularly used. The décor had been completed tastefully and some original features such as a fireplace added character to the room. Previous requirements were examined. A risk assessment for the kitchen was in place but this did not consider that mobile residents of which there were two in the home currently could potentially access the kitchen. It is therefore outstanding that risk assessments Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 16 must be taken from this perspective and any identified actions completed. This is an outstanding requirement from previous inspections The Manager said that all radiators had been covered. This was observed in the lounge other areas were not checked at this visit. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 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 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): 27,28,30 Service users were being cared for by a stable staff team who communicated well with each other. EVIDENCE: Staffing rota’s were being kept these indicated that staffing levels were being maintained in relation to the number and dependencies of service users being cared for. There were 19 care staff employed at the home of these 5 had achieved at least NVQ (National Vocational Qualification) level 2 in care qualifications. Four more staff had enrolled on courses. It is calculated that even if these four staff achieve their qualifications that the home will not have met the sufficient percentage of staff with relevant care qualifications. This must be reviewed. Staff training records were examined these confirmed that staff were receiving annual updates in moving and handling training, training in dementia care, handling of medicines, fire safety and first aid. The Manager had established links with a local college to access training for staff. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 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 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): 31,33,34,36,37,38 There appears to tiers of management in place at the home with communication systems in place to react appropriately to the quality assurance audits undertaken. EVIDENCE: Since the last inspection the Manager has successfully completed the Commission for Social Care Inspection fit person process and is formally registered as Manager of the home. A condition of registration is in place that the Manager completes the Registered Managers Award (NVQ level 4 in management) by September 2005. This has not been met. Discussion with the Manager confirmed that she has still has 4 units to complete but this is progressing. A quality assurance format was in place which was detailed and wide ranging in the aspects it considered. There were monthly visits recorded made as required by the Provider and meetings held on a monthly basis between the Provider and the Manager to discuss the quality assurance review. This did Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 19 detail some comments from residents. In addition the Manager was in the process of undertaking a survey regarding care so far 2 questionnaires had been returned. No service user comments were included in the Service User Guide. Staff meetings are held and minutes recorded. Some residents meetings have been held though the minutes on the notice board related to a meeting held on 10.9.04 so these appear to be infrequent. A valid public liability insurance was displayed. Records for the purpose of establishing financial liability were not requested at this visit. The Manager stated there was a consistent staff team at Kidsley range with no new staff being employed since the last inspection. Staff supervision records were examined. These indicated that some supervision of care staff had been completed but the dates of this confirmed that this was infrequent and did not meet National Minimum Standards. There was no formal supervision of nursing staff and the format available for supervision was a structured one reflecting the role of the carer as opposed to the role of the nurse. It is an outstanding requirement from previous inspections that all staff must receive appropriate supervision. A range of service records were examined. These confirmed that routine checks and servicing had been completed. Accidents were recorded and audited as part of the monthly quality assurance visits. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 x 3 x x x x x x STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 3 x 2 3 3 Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 21 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 OP7 2 15 Standard Regulation Requirement Care plans must be in a format which clearly records assessed needs and the care delivery instructions as to how these are to be met Residents must be consulted regarding their wishes if they become terminally ill. This must be reviewed regularly. Where this is considered inappropriate the reasons for this must be recorded Partially completed Timescale not met 3 OP12 4 15,16 Service users individual interests/assessed social needs must be recorded with a plan of care on how these are to be met Timescale for action 30/11/05 OP11 12(2) 31/08/04 30/11/05 OP15OP26 13(4)(a) The home must undertake a risk assessment of the kitchen and areas and ensure all appropriate actions are taken to protect the health and safety 31/12/03 of residents. Timescale not met 5 OP16 Kidsley Grange 22(1)(4) The provider must provide a response to complaints within 28days of receipt 31/10/05 or provide an update if to DS0000002107.V254850.R01.S.doc Version 5.0 Page 22 complainants within 28 days if further investigations are required 6 OP18 13(6) 18 All staff must receive training on the multi agency protection of vulnerable adults procedures form Derbyshire County Council Timescale not met 7 The home must have a procedure for the handling of allegations of abuse. This should refer to the Derbyshire Protection of Vulnerable Adults procedures which are there to protect the service users residing in Derbyshire The home must plan to ensure at least 50 of care staff achieves at least NVQ level in care by 2005. Timescale not met 9 OP31 9 The Provider must ensure the registered Manager achieves an NVQ level 4 or equivalent in Management Condition of registration not met 10 The views of service users must be sought and the findings made available in the service users guide. This was in the process of being completed Timescale not met 11 OP36 18 The registered person must ensure that all staff receive formal supervision Previous timescale of 31.12.03 has not been met 31/12/03 26/02/05 OP18 13(6) 31/12/03 8 OP28 18 31/12/05 30/09/05 OP33 24(a) 30/03/04 Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 23 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 Refer to Standard OP36 OP36 Good Practice Recommendations Staff supervision should be completed at least six times annually for all staff It is recommended that the supervision format should be broadened to allow more flexibility. Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Kidsley Grange DS0000002107.V254850.R01.S.doc Version 5.0 Page 25 - 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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