Inspection on 20/06/05 for Lindley Grange Nursing Home

This inspection was carried out on 20th June 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

Lindley Grange Nursing Home 05/09/07

Lindley Grange Nursing Home 13/09/06

Lindley Grange Nursing Home 26/10/05

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 Acre Street Lindley Huddersfield HD3 3EJ Lead Inspector Helen Battle Unannounced 20 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lindley Grange Nursing Home Address Acre Street Lindley Huddersfield HD3 3EJ 01484 460557 01484 659336 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) BUPA Care Homes (GL) Ltd Mrs Carol Bottrill Care home with Nursing 45 Category(ies) of DE(E) - Dementia over 65 - 45 registration, with number of places LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 09.09.04 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. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection at Lindley Grange on Monday 20th June 2005, and was conducted by two inspectors commencing at 09.30am and finishing at 3.30pm. Ruth Glendinning, the deputy manager, was present at the inspection. This visit also incorporated an investigation into a complaint received regarding the care provision at Lindley Grange. The following inspection methods were used: sampling of records, care plans, individual discussion with six service users and four members of staff, discussion with the management, tour of the premises and document reading. What the service does well: What has improved since the last inspection? What they could do better: Care planning has deteriorated since the last inspection and now needs attention to ensure that all care plans meet the individual needs of service users. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 6 Where a change has occurred in a service user’s condition, assessment and plans should be reviewed. This has not happened in one instance identified during this inspection. Medication records and the practice of administration of medication needs to be improved to ensure the safety of service users. Movement and handling practices need to be improved to ensure the safety of both service users and staff. Senior staff should challenge any poor practice. 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 J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 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 LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 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) 3, 5 Service users are assessed before admission. Relatives have an opportunity to visit the home prior to admission. EVIDENCE: Pre-admission assessments were seen for three service users, where one of these was incomplete, a community care assessment was in place. These assessments were generally detailed and included information about daily living activities, likes and dislikes and previous medical history. There was written evidence that the family of one service user had visited the home prior to making a decision that Lindley Grange was suitable for their relative to live there. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 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 standard(s) 7, 8, 9, 10. Since the last inspection care planning has deteriorated and does not always provide staff with the information they need to meet service users’ needs. The systems for the administration and recording of medication are poor and potentially place service users at risk. Personal support is offered in such a way as to promote and protect service users’ privacy, dignity and independence. EVIDENCE: Three service user care plans were examined. Two were found to contain relevant information. The third did not have care plans relating to the management of specific challenging behaviour and communication. Risk assessments were in place which included falls, tissue viability, nutritional status and mobility. One movement and handling plan had not been updated to reflect the recent changes to a service user’s deteriorating condition. There has been a deterioration in the care planning process since the last inspection; this must be improved. Not all medication checked tallied with the records held. There were gaps in recording medication checked in, brought forward and administered. Issues LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 10 were raised about practices related to service users who are not compliant in taking medication. These issues should be investigated by the manager. The policies and procedures for the administration of medication should be reviewed and these issues addressed quickly. It was observed that service users are treated with respect and that their privacy is maintained. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 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 standard(s) 12, 13, 14, 15 The provision of activities at the home is suitable for the needs of the service users. Contact with relatives and friends is maintained. The meals in this home are good, offering both choice and variety and catering for special needs. EVIDENCE: An activities co-ordinator is employed and evidence was seen of art work, outside entertainers, music, and one to one time such as taking individual service users out for a walk. Visitors were observed to be welcomed to the home throughout the day and visit at various times. The atmosphere was relaxed and staff were seen to respond to service users in a kind and caring manner. The meals provision at the home is good. Service users were observed to enjoy the lunchtime meal of steak and kidney pie with potatoes and vegetables, followed by a sweet of plum crumble and custard. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 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 standard(s) 16, 18. The home has a satisfactory complaints procedure with evidence that issues are listened to and acted upon. The home has an adult protection and whistle blowing policy and procedure in place to help ensure that service users are protected from abuse. EVIDENCE: Investigations into complaints were seen to be thorough and detailed. Issues raised by relatives in a more informal manner were also seen to be documented and acted upon. Staff spoken to were confident in speaking to the manager and that any concerns would be addressed. They stated that the manager is very approachable. Adult protection and whistle blowing policies and procedures are in place. A complaint was investigated during this inspection and some of the findings are included in the requirements and recommendations of this report. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 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 standard(s) 19, 20, 22, 23, 24, 25, 26. The standard of décor and furnishings within the home is good. The home is well maintained and clean. EVIDENCE: Service users’ bedrooms are decorated as they become vacant. Communal lounges and dining rooms are decorated to a satisfactory standard. Furniture provided is of a good standard. Service users are able to bring their own possessions into the home to personalise their rooms. Specialist equipment is provided to meet the needs of the service users. The home was clean and pleasant on the day of the inspection. There is a safe, enclosed well maintained garden for service users to enjoy. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 14 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, 30. Staff morale appears satisfactory. Poor practice in movement and handling potentially places service users and staff at risk. EVIDENCE: Staffing levels have been maintained since the last inspection. Staffing levels meet previously agreed levels. Movement and handling training is provided and staff spoken to confirmed that they have received the training and subsequent updates. However, during the inspection two service users were moved and handled in an inappropriate manner by staff. This must be addressed as poor practice puts service users at risk. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 15 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, 33, 34, 35, 38. The manager of the home is well qualified and demonstrates competence and ability in managing the home. Service users’ financial interests are safeguarded. The health, safety and welfare of service users and staff are at risk of being compromised due to incidents of poor moving and handling practice. EVIDENCE: The manager has a good understanding of the areas in which the home needs to improve. Staff spoken to stated that the manager is approachable, listens and actions any issues which need addressing. All those spoken to appeared to have confidence in the manager. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 16 Service users’ personal monies are kept securely and procedures are in place to safeguard these monies. Weekly and monthly health and safety checks are recorded as being carried out as required. Poor moving and handling practice was observed and could potentially place staff and service users at risk. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 17 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 x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 3 3 x x 2 LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 18 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 7 Regulation 15 Requirement Timescale for action 31 July 2005 2. 9 13(2) Care plans must set out in detail the action which needs to be taken by staff to ensure that all the aspects of the health, personal and social care needs of the service user are met. All medication in the home must 31 July be accounted for in the records. 2005 Practice relating to the administration medication for service users who are not compliant must be explored. 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. 3. Refer to Standard 28 30 38 Good Practice Recommendations Senior staff should challenge poor practice specifically in relation to moving and handling. The manager should check the understanding of staff following movement and handling training. Correct moving and handling practice should be used at all times to ensure the health, safety and welfare of service users and staff are promoted and protected. LINDLEY GRANGE J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 19 Commission for Social Care Inspection Brighouse CSCI 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 J51J01_S1118_Lindley Grange_V229228_200605.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!