Inspection on 13/09/06 for Lindley Grange Nursing Home

This inspection was carried out on 13th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lindley Grange Nursing Home 05/09/07

Lindley Grange Nursing Home 26/10/05

Lindley Grange Nursing Home 20/06/05

Lindley Grange Nursing Home 09/09/04

Lindley Grange Nursing Home 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Lindley Grange Nursing Home Acre Street Lindley Huddersfield West Yorkshire HD3 3EJ Lead Inspector Key Unannounced Inspection 13th September 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 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. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lindley Grange Nursing Home Address Acre Street Lindley Huddersfield West Yorkshire HD3 3EJ 01484 460557 01484 659336 bottrilc@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd 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) Mrs Carol Ann Bottrill Care Home 45 Category(ies) of Dementia - over 65 years of age (45) registration, with number of places Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can provide accommodation and care for four named service users under 65 years of age. 26th October 2005 Date of last inspection Brief Description of the Service: Lindley Grange provides nursing care and accommodation for up to 45 older people with dementia type illnesses. The accommodation is on two floors and all the bedrooms have ensuite facilities. Each floor also has lounge and dining room facilities. The home is a stone, purpose built nursing home set in its own grounds. It is approximately two miles from Huddersfield and is on a main bus route. Lindley village, with all its amenities, is located within a short walk. There is a safe garden for service users and ample parking to the front and side of the building. The provider informed the Commission for Social Care Inspection on 13 September 2006 that the fees range from £344.71 to £700.00 per week. There are additional charges for hairdressing and chiropody. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by one inspector. The inspector arrived at the home at 9.30am and left at 5.00pm. During this visit the inspector spoke to some of the service users, visiting relatives, some of the staff and the home’s management. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the building. Prior to the inspection, ten service user questionnaires were sent to Lindley Grange to obtain the views of service users living at the home. Seven completed questionnaires were returned; some had been completed by relatives on the behalf of service users. There were forty three service users living at the home on the day of this inspection. Surveys were sent to ten relatives and friends of service users, GPs and social workers. At the time of writing this report, the inspector had received no responses from relatives and two GPs. There were no responses from social workers. Other information used as part of the inspection process included notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider, and a pre-inspection questionnaire completed by the manager. The inspector would like to thank everyone for their assistance during the inspection process. What the service does well: The home has a welcoming atmosphere and staff are relaxed and friendly with service users and visitors. All service users are assessed to ensure the home can meet their needs prior to admission. Service users are treated with respect and their privacy maintained. This was confirmed during observation on the day of this visit and from speaking to a visiting relative. The recruitment processes and the quality monitoring systems at the home are robust to ensure the protection of service users. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 6 The activities provided at the home are of a good standard, offering both group and one to one activities. The environment is well maintained and the addition of the sensory garden is a positive feature, enjoyed by service users. The meals provided are of a good standard. 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. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 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 Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service users have their needs assessed prior to admission into the care home. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Copies of Community Care assessments and pre-admission visit records were seen in the records held for four service users. The pre-admission assessment visits are carried out by the registered manager or the deputy manager. Service users’ families generally visit the home prior to admission. It was reported that the family of a service user admitted during this visit had visited the previous evening. This home does not provide intermediate care. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Service users’ health, personal and social care needs are set out in the individual plan of care, however these are not always updated following an evaluation. Risk assessments are carried out. Generally, the service users are protected by the home’s medication policy and procedure. Service users are treated with dignity, respect and privacy. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care records of four service users were examined. All had care plans in place related to the needs of the service users. These care plans had been reviewed monthly and a record kept of the review, however the actual care plan had not been altered to reflect the review. This was confusing. Risk assessments were in place relating to tissue viability, falls and nutritional status. Daily records were varied in the amount of detail documented. Some entries were good and reflected the nursing care and support given to individuals on a Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 10 daily basis, however others were less detailed and did not reflect the standard of care given. There was evidence of input from GPs, specialist nurses and from dentists and opticians. The issues raised regarding care plans during this visit had already been identified by the Responsible Individual for the home during a monthly management visit. This had been brought to the attention of the Commission and an action plan devised and implemented. Work to remedy these issues was already underway. Medication was checked for two service users. The medication held in blister packs tallied with the records held. Three amounts of “boxed medication” were checked and there were discrepancies in these. The records did not reflect how many tablets had been administered where there was an option of “one or two” to be given. Accurate records of medication must be maintained. During this visit, service users were observed to be treated with respect and their dignity maintained by staff. This was confirmed by a relative who was spoken with at the time of the visit. One service user stated that the staff were kind, another service user said that they were able to have a laugh and a joke with the staff and that they were all good. Responses from surveys included the statements “Staff are helpful”, “mother looked after well”, and “they cope with the demanding load an EMI unit poses extremely well”. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The service users’ cultural, religious, social and recreational needs are being met and they are supported to maintain contact with their family and friends. The service users are able to exercise choice and control over their lives. The home provides the service users with a varied and nutritious diet. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A dedicated activities co-ordinator is employed at the home and has held this post for some time. She evidently knows the service users well and what their likes, dislikes and abilities are regarding how they like to spend their time. A record of previous hobbies and interests are documented after speaking with families and friends. Activities provided for service users have included painting, card games, music and movement, massage, flower arranging, balloon games, musical entertainers, fashion show, gardening, reminiscence. The activities coordinator also does a lot of one to one work with service users who choose not to join in group activities or who are unable to join in. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 12 Since the last inspection, a huge amount of work has been put into the garden at the home and a new sensory garden has been built. This has been made possible with the help of local young people who assisted in digging out the area. The garden has now been completed and is reported to be enjoyed and well used by service users. This was confirmed on the day of this visit with a number of service users being observed to wander in and out to the garden and appear to enjoy this area. Breakfast was still being served at the beginning of this visit and service users appeared to be enjoying a full cooked breakfast. This was nicely presented and service users were being assisted to eat their meal, where required, in an appropriate manner. The atmosphere was relaxed and unhurried. Lunch was served only a couple of hours following breakfast. Again, the meal served looked appetising and consisted of mince, carrots, cabbage, potatoes and gravy followed by sponge rhubarb and custard. One service user was asked why they weren’t eating their meal and replied that they were still full from breakfast. The manager said that this would be explored and that the views of staff, service users and relatives would be sought on how to improve the timing of meals. Contact is maintained with families and friends. Relatives were seen to visit the home during this visit and were seen to be made welcome by the staff. A relatives’ meeting is held every month and is said to be fairly well attended. Service users are encouraged to exercise control in their day-to-day lives where possible. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Service users, their relatives and friends are confident in raising any concerns and complaints. The service users are protected from abuse. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The complaints procedure is displayed in the entrance area to the home. Feedback on the surveys indicated that service users and relatives know who to speak to if they had any concerns. The complaints log is now easily accessible for senior staff to access if the manager is not at the home. An audit of complaints is carried out monthly. Staff are due for a refresher in adult protection training. A senior member of staff has recently started a course to enable her to train other members of staff in adult protection issues. This training is to be completed by March 2007. Staff spoken to on the day of the inspection showed a good awareness of adult protection issues and procedures. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 The service users live in a safe and, overall, a well-maintained environment that is generally clean and hygienic. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The environment of the home is maintained to a good standard. When a room becomes vacant it is redecorated. All the communal areas are light and easily accessible for service users to walk in. Furniture is of a good standard. The home was clean and generally free from unpleasant odours during this visit. One area which did have a slight odour was being addressed. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 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, 30 Staff are employed in sufficient numbers and receive induction and ongoing training. The recruitment process ensures the service users are sufficiently protected by the home’s recruitment policy. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Staffing levels provided at the home are sufficient to meet the needs of the service users. Generally in the morning there are 2 nurses and 7 care assistants; in the afternoon there are 2 nurses and 6 care assistants; and at night there is 1 nurse and 4 care assistants. These levels must be maintained due to the dependency levels of the service users living at the home and due to the layout of the building. The recruitment records for four members of staff were examined. All were found to have the required checks and references in place prior to the member of staff commencing work in the home. Induction training is comprehensive. Mandatory training provided includes movement and handling, health and safety and fire training. Other training staff have attended or are due to attend includes dementia care, infection Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 16 control, nutrition and managing challenging behaviour. Fifty per cent of care staff working at the home have achieved the NVQ level 2 award in care. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 The home is run and managed by a manager who is fit to be in charge. Generally the home is run in the best interests of the service users. The financial interests of the service users are safeguarded. The health and welfare of service users and the staff is promoted and protected. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The manager of the home is an experienced nurse who is able to discharge her duties fully and effectively manages the home. The service users benefit from the management approach at the home, where their best interests are kept in mind with any decisions which are made. This is evidenced by the inclusion of Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 18 service users with the sensory garden project, and by the response of the manager in reassessing the meal arrangements. There are no personal monies held in the home for service users. Staff generally receive supervision every two months and appraisals every six months. Tests of the fire alarm and emergency lighting system are recorded as being carried out weekly. There have been four fire drills carried out since the last inspection. Hot water temperatures are checked and recorded as required; any remedial action taken is also recorded. There were no health and safety issues noted during the tour of the building on this visit. There are robust quality monitoring systems in place for each area of the home. Surveys are sent out to relatives periodically and the results published. The most recent publication is dated February 2006. The results from this are positive. Comments included “The staff are loving and caring”, “they take good care of their patients and they were kind to me”, “they are friendly and they keep the place a very clean environment”. Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP18 Regulation 13(6) Requirement All staff must receive refresher training in identifying and responding to abuse. Previous timescale of 30/11/05 not met. Timescale for action 30/06/07 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 Care plans should be reviewed monthly to ensure they reflect the current needs of the service users. Daily records should reflect the actual care and support delivered. Care should be taken to ensure that accurate records are maintained for medication stored in boxes. Where an option of “one or two” tablets is prescribed, the actual number of tablets administered should be recorded. 2. OP9 Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lindley Grange Nursing Home DS0000001118.V296198.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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