Inspection on 30/01/06 for Kidsley Grange

This inspection was carried out on 30th January 2006.

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 28/09/05

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 30th January 2006 09:05 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.V281420.R01.S.doc Version 5.1 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.V281420.R01.S.doc Version 5.1 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 Vacant Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 day care places Date of last inspection 28th September 2005 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.V281420.R01.S.doc Version 5.1 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. The focus of this inspection was to assess compliance with previously listed requirements and recommendations and to assess key standards that had not previously been assessed in this inspection year. Various records including care planning records were examined the findings are recorded in the body of this report. The Acting Manager Emma Wright was on duty at the time of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 6 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.V281420.R01.S.doc Version 5.1 Page 7 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): EVIDENCE: No standards in this section were formally assessed at this visit as all key standards were assessed as being met at the inspection undertaken on 28th September 2006 A requirement is listed however as the Statement of purpose requires updating to reflect the change in Manager at the home. Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 8 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): 7,9,11 Care plans were found to be insufficiently detailed in recording all service users assessed needs and did not reflect the abilities and preferences of the service users in how care was to be delivered. EVIDENCE: Samples of two residents care files were examined. The findings of the last inspection report of a cumbersome and fragmented method of recording the plan of care remain. The recording format used was not based on recording assessed care needs. Care plans were found to be repetitive in content and gave little detail on service user preferences and individual abilities. There were examples however of some assessed needs not being not being included as part of the plan of care for example one service user with diabetes did not have a care plan in place to detail how this was to treated and monitored. One service user had a marked weight loss with no plan of care evident to address and monitor this. It was also found that care plans were not fully documenting psychological needs or detail how these were to be addressed. Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 9 There was no evidence of consultation with service users regarding their plan of care or a record to state that this was not considered appropriate. One service user was observed to be assisted from the table to the lounge and was left with food around their mouth and a stained jumper. This affects the dignity of service users to appear in such a manner. There was evidence within care plans of visits being made by GPs, outpatient appointments and service users receiving a chiropody and optician service. The Provider employs a physiotherapist who visits the home on a regular basis to provide assessment and support to service users this is included in the home fees. Where needs had changed regarding optical needs this was addressed in one service users file by requesting an reassessment by the optician. A range of risk assessment tools were included in care plans and reviews of the plan of care were documented. The storage and administration of medicines was inspected at this visit. Where medication administration records had been handwritten these had not always been checked and verified by a second staff member. Some omissions were evident on medication administration records where a code had not been recorded to indicate reason for non-administration. Where a variable dose of a medication had been prescribed it was inconsistently recorded what actual dosage had been administered. Where drugs were disposed of records were kept. The treatment room was found to hot on the day of the visit due to the siteing of a boiler in the room. Records of daily temperature checks confirmed temperatures being reached of up 28ºc on a regular basis. The packaging on most medications states that they must be stored at temperatures no higher than 25ºc and this must be addressed as the temperature may affect the efficacy of the medications being stored at a high temperature. There was found to be inconsistent recording of service users post death wishes. One care plan documented that this had not yet been discussed but did not detail the reason for this. This is an outstanding requirement from previous inspections Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 10 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): 12,14 Some activities were taking place at the home however there was poor documentation to assess the appropriateness of these in accordance with service users assessed needs. Many of the activities recorded were passive ones with no active participation being recorded from the service user. EVIDENCE: A new cooker was being fitted on the day of inspection and due to problems with this an impromptu meal of fish and chips was served. The majority of service users spoken with enjoyed this. The previous requirement relating to the recording of assessed social needs and how these are to be met was assessed. Care plans contained little detail of service users preferences and likes regarding social needs and the requirement remains listed. Some activities were recorded on separate sheets for each service user. Many of these activities were passive such as watching television/films or listening to music. There was no record of interactions or discussions following these activities to indicate if service users had enjoyed this or no record of the service users abilities during activities such as understanding/concentration or communication. Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 11 One service user spoken said there was not many activities taking place but there were occasional bingo sessions. Church services were held in the home on a twice monthly basis. Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 There is not sufficient staff training and clear procedures in place to ensure that any allegations of abuse are handled appropriately. EVIDENCE: Since the last inspection two complaints had been received one at the home and one was sent to the Commission for Social Care Inspection. Assessment of the responses revealed that for one complaint no actions had been recorded and no response given to the complainant within 28 days. It is an outstanding requirement that complaints are dealt with or interim responses given within this time. A complaints procedure was on display for visitors to access if they wished. Discussions with the Acting Manager revealed that Protection of vulnerable adults training had still not been undertaken by all staff. Some dates for this were said to have been booked. As has been previously identified there was inconsistent information on how to allegations of abuse are to be handled A Derbyshire County Council booklet was available advocating locally agreed multi agency approaches whereas the procedure in the home advocated internal investigation. This is an outstanding requirement from previous inspections. Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.24.26 The communal areas are generally well maintained and presented however the bedrooms and bathrooms of the home are in need of refurbishment. EVIDENCE: The communal areas of the home were found to be clean and homely. They were well maintained and it was evident that service users each had their own established area where they chose to sit. There was evidence that trees and bushes had been trimmed and the grounds of the home were tidy. A sample of bedrooms were viewed. It was evident that some carpets were stained and worn and in need of replacement. There was wear and tear evident to the bases of divan type beds which require replacement. Bedrooms furnishings appeared to be tired and outdated with some bedrooms having insufficient furniture for example one double bedroom had only 1 bedside Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 14 locker, 2 chairs and a three door wardrobe for 2 service users. There were no lockable facilities available for service users to use. The Acting Manager reported that the providers were aware of the need for refurbishment and 6 sets of bedroom furniture were on order. The carpet in the upstairs corridors was significantly worn and required replacement as it was becoming threadbare and potentially dangerous at some points. There was some minor damage in one bath from the use of a hoist. Plaster damage was evident on one bathroom door. The flooring in one bathroom had a hole in it. The home was found to generally clean and tidy. Staff were observed to wear aprons and gloves when required. The laundry was suitable for purpose and secure. A sluicing disinfector was available. Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 Whilst staffing levels were appropriate there was work required to ensure staff were appropriately recruited supervised and trained. EVIDENCE: Occupancy of the home at the time of the inspection was 17 service users, 16 of whom required nursing care and one requiring personal care only. Staffing levels in the home were considered to be acceptable for the number of service users being cared for. Four care staff in the home out of 18 had completed NVQ (National Vocational Qualification) level 2 in care. Four more staff were enrolled on courses. This falls short of the required 50 of staff that the National Minimum Standards describe as being required. A recent audit of staff personnel files was available which had been completed by the Acting Manager this and discussions with the Acting Manager confirmed that not all required checks were in files and some aspects Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35,36 Work is required to ensure that management processes are implemented fully in the areas of supervision, recruitment, and the documenting and implementing of assessed care needs. EVIDENCE: Since the last inspection a new Acting Manager has been appointed. An application has not yet been submitted to the Commission for Social Care Inspection to formally register the Manager. Some monies were kept in the home safely on behalf of service users. A sample of records relating to these was examined. Transactions were recorded and verified by two signatures. Balances checked correlated. Discussions revealed that most service users required assistance with financial matters and some information was included in care files on the Power of attorney where this was in place. Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 17 Staff supervision was discussed with the Acting Manager. An audit was available which indicated that many staff had not received supervision in the past six months. A format was available for recording supervision which No consultations have been held with service users as was required on the previous inspection report and this requirement remains listed. Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 3 2 x x 2 x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 3 2 x x Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 19 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 2 Standard OP1 OP7 Regulation 4 15 Requirement The Statement of purpose must be updated to reflect the change in Manager at the home 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 Previous timescale not met 30/11/05 The service users care plan must detail all service users assessed needs Care plans must be made available to residents, records should be kept to record if it has been assessed if residents lack the capacity to understand care plans Service users personal hygiene needs must be met at all times The provider must ensure that all medications must be stored at or below 25ºc Medication administration records must include a code to indicate administration or reason for non administration for all DS0000002107.V281420.R01.S.doc Timescale for action 31/03/06 30/04/06 3 4 OP7 OP7 15 15 30/04/06 30/04/06 5 6 7 OP7 OP9 OP9 15 13,17 Schedule 3 13,17 Schedule 3 28/02/06 31/03/06 28/02/06 Kidsley Grange Version 5.1 Page 20 8 OP9 13,17 Schedule 3 13,17 Schedule 3 12(2) 9 OP9 10 OP11 medications which are due to be given A record must be kept of the dose of medication administered to a service user where a variable dose is possible. Where medications are prescribed on a regular basis these must be administered or a record maintained of the reason for ommisions 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 Previous timescale not met 31/08/04 Service users individual interests/assessed social needs must be recorded with a plan of care on how these are to be met Previous timescale not met 30/11/05 28/02/06 28/02/06 31/03/06 11 OP12 15,16 30/04/06 12 OP16 22(1)(4) The provider must provide a response to complaints within 28days of receipt or provide an update if to complainants within 28 days if further investigations are required Previous timescale not met 31/10/05 28/02/06 13 OP18 13(6)18 All staff must receive training on the multi agency protection of vulnerable adults procedures form Derbyshire County Council Previous timescale not 26/02/05 31/03/06 14 OP18 13(6) The home must have a DS0000002107.V281420.R01.S.doc 31/03/06 Version 5.1 Page 21 Kidsley Grange 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 Previous timescale not met 31/12/03 15 16 17 OP19 OP19 OP19 23 23 23 The corridors on both floors of the home must be re carpeted The corridors on both floors of the home must be redecorated A refurbishment plan for the bedrooms and corridors of the home must be drawn with timescales The damaged flooring in the downstairs bathroom must be repaired/replaced The plaster damage in the downstairs bathroom must be repaired and made good Bedroom carpets must be replaced where they are stained, worn or damaged Service user bedrooms must contain adequate furniture in accordance with the listing of National Minimum Standards 24 to meet service users assessed needs An assessment must be made of all beds in the home and where beds are damaged or stained they must be replaced The home must plan to ensure at least 50 of care staff achieves at least NVQ level in care by 2005. Previous timescale not met 31/12/05 The Provider must submit an application to register a Manager for the home DS0000002107.V281420.R01.S.doc 30/06/06 30/06/06 28/02/06 18 19 20 21 OP21 OP21 OP24 OP24 23 23 23 16 30/06/06 30/05/06 30/07/06 30/06/06 22 OP24 16 30/05/06 23 OP28 18 31/12/05 24 OP31 9 30/03/06 Kidsley Grange Version 5.1 Page 22 25 OP33 24(a) 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 Previous timescale not met 30/03/04 30/05/06 26 OP36 18 The registered person must ensure that all staff receive formal supervision Previous timescales of 31/12/03 has not been met 30/03/06 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 2 Refer to Standard OP21 OP36 Good Practice Recommendations A refurbishment of bathing facilities should be considered Staff supervision should be completed at least six times annually for all staff Kidsley Grange DS0000002107.V281420.R01.S.doc Version 5.1 Page 23 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.V281420.R01.S.doc Version 5.1 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. 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