Inspection on 28/09/05 for Mandeville 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 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mandeville Grange 04/02/10

Mandeville Grange 23/10/09

Mandeville Grange 11/11/08

Mandeville Grange 23/11/06

Mandeville Grange 29/12/05

Mandeville Grange 14/03/05

Mandeville Grange 10/08/04

Mandeville Grange 28/01/04

Mandeville Grange 21/01/03

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Mandeville Grange 201-203 Wendover Road Aylesbury Bucks HP21 9PB Lead Inspector Sue Smith Unannounced 28 September 2005 10:00 a.m. 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. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mandeville Grange Address 201-203 Wendover Road, Aylesbury, Buckinghamshire, HP219PB 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) 01296435320 Mr A.S. Dhot Mrs S.K. Dhot Mrs Minerva Patti Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 General Nursing Care ( age 50 plus including one 39 plus) Date of last inspection 14 March 2005 Brief Description of the Service: Mandeville Grange Nursing Home is situated on the outskirts of Aylesbury Town, which provides a variety of shops and other local amenities. The Home provides Nursing care for up to thirty-one Service Users, who are accommodated on two floors of the building. All floors are accessible by stairs, a passenger lift or stair-lift. Qualified Nurses and Carers staff the Home. The Manager is a suitably qualified Nurse; in addition to managing Mandeville Grange she also manages The Gables Nursing Home, (also owned by the proprietors) which is situated approximately five minutes from Mandeville Grange. This is possible through the employment of two capable and supportive Deputies Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over 2.5 hours. The Manager was available throughout the inspection with the Proprietor on site and available if required. The inspector conducted a full environmental tour of the home, assessed several documents, which included: Pre-admission assessments, care plans and medication procedures. During the inspection, the Inspector spoke with 3 staff members and 4 Service Users to gain their views. The Inspector also spoke with 3 visitors to the home to gain their views on the service provided. There were no verbal complaints made throughout the inspection. 20 of the National Minimum Standards were assessed during this inspection with 18 fully met and 2 almost met. The Home has received no requirements and 2 recommendations to further improve practice as a result of this inspection. Standards not fully assessed will be addressed at the next inspection undertaken by the Commission. This report is a reflection of what was found on the day of this inspection. There were a number of issues the Home is presently addressing that will be re-assessed at the next inspection to ensure these have been resolved, these were: medication administration for such things as lactulose, the fitting of the remaining 6 door guards, filling the vacant Activities Co-ordinator post, thus continuing with the wide range of activities previously offered at the home. The 2 recommendations were made to address the need to review such things as bathing regimes to ensure they are in line with current wishes and preferences of Service Users and to ensure the home continues to risk-assess radiators and apply covers to minimise any risks identified. The home continues to be an efficiently managed home with a committed staff team. The Inspector would like to take the opportunity to thank the Service Users, family members and staff for their contributions and support whilst undertaking this inspection. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 6 What the service does well: What has improved since the last inspection? Water temperatures tested were reflective of a safe and recommended temperature. These are now regularly monitored with readings recorded. Additional door guards have been fitted to bedroom doors to ensure the safety of Service Users. The programme of redecoration is continuing with areas identified throughout the home for improvement actioned as soon as is reasonably practicable. A new recording system is in place for monitoring the weight of Service Users. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 7 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. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 8 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 Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 9 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) 2, 3. All Service Users have a signed copy of the terms and conditions of admission to the Home; this ensures their personal rights are protected. All Service Users are subject to a full pre-admission assessment to ensure the Home is able to meet their needs prior to admission. EVIDENCE: A copy of the terms and conditions for each Service User can be found in the individual care plan file, the Service User or a family member signs these. A full pre-admission assessment is undertaken by the Home prior to any admission. These are found in the individual care plan file, information contained in these assessments is then used to support the nurse to formulate care plan objectives, which will ensure the needs of Service Users are met. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10. All Service Users have a full plan of care which is regularly reviewed to ensure the home continue to meet the individual needs of Service Users. Staff demonstrated a sound understanding of the needs of Service Users and their interactions and relationships with them was positive, which enabled Service Users to express their thoughts, feelings and needs. The Home has a rigorous medication procedure in place, all medication is stored, administered and disposed of in a satisfactory manner ensuring Service Users are protected by the systems in place. Staff practice giving and assisting with such elements as personal care and arrangements for medical examination ensure the privacy and dignity of Service Users. EVIDENCE: Each Service User has a care plan file which contains relevant assessments for such things as pressure wound management, mobility (manual handling) day and night plans, daily reports, specific health issues such as diabetic care needs, monthly weight, TPR and BP monitoring. Each assessed need is then Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 11 documented as an individual plan of care, which has objectives, and actions to be implemented reflected. All care plans are reviewed monthly with additional needs reflected as necessary. The care plans were found to be maintained to a high standard, all assessments were reflective of review dates and signatures. Staff were observed throughout the inspection carrying out their duties in a professional and sensitive manner. Service Users and family members spoken with were complimentary of the support offered. Issues raised by family members to further support Service Users were discussed with the Manager and Deputy Manager, the response to these were positive and reflective of a proactive management approach. There were no verbal complaints made by Service Users or family members. One recommendation has been made for nursing staff to review current regimes such as bathing rota’ to ensure they are reflective of current wishes and preferences. The Home’s medication procedures were assessed during this inspection. All medication is stored appropriately in lockable metal facilities. Controlled drugs are stored appropriately; the inspector assessed medication for one Service User and found records held to be accurate, and appropriately signed by two members of staff. The Home does have an issue with the administration of such things as lactulose, due to limited storage space in the medication trolley. The Home is in the process of addressing this issue and is exploring how to best administer whilst working within the pharmaceutical guidelines. Due to the Home working towards resolving this issue, the inspector has not issued a requirement at this time. However, the system in place will be further assessed at the next inspection by which time the Home should have resolved the problem. All MAR (Medication Administration Records) were found to be up-to-date and appropriately signed with no gaps. There was no out-of-date medication held in the home. Personal care is implemented in the privacy of the Service Users’ own room or communal bathrooms. Staff ensure the privacy and dignity of Service Users is maintained throughout. Care is implemented taking into consideration the personal preferences of Service Users. There is a flexible approach to such things as bathing times, however the routines in place could be further reviewed to ensure original preferences are still in line with the Service Users’ current wishes. Service Users spoken with were complimentary of the staff team and the time they give to ensure personal needs are met. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13. The Home is advertising for a replacement Activities Co-ordinator, this will ensure the social and recreational needs of Service Users continues to be met at the home. Visitors are welcomed during all reasonable hours with no restrictions in place. This enables Service Users to maintain their friendships and relationships whilst residing at the Home. EVIDENCE: At this time, the Home is without an Activities Co-ordinator. This has had an impact on the amount of activities offered at the home. Previous to this inspection, the Home has always offered a wide variety of stimulating and enjoyable activities. The organisation will be re advertising this post in the next addition of the local newspaper and it is hoped a successful candidate can be found. Service Users did make reference to the shortage of activities at this time in the home and are looking forward to this service recommencing. The inspector appreciates that until such time as this post is filled, the activities on offer have reduced in numbers. The inspector will reassess this standard at the next inspection. Visitors spoken with during the inspection felt welcomed to the Home and supported enough to voice their concerns. Positive feedback was received in Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 13 relation to the care provided by the Home. In addition, visitors spoken with highlighted areas that could be explored to further improve the facilities and service offered. All were complimentary of the Home and the professional conduct of the staff team. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16. The Home has a comprehensive complaints procedure with records of complaints and investigations open to inspection. The complaints procedure is made available to Service Users and significant others, which ensures all relevant persons are able to make a formal complaint appropriately. EVIDENCE: There have been no complaints received at the Home or directly to the Commission in the past 12 months. The Manager ensures that she is available to Service Users and family members to discuss any concerns, thus ensuring all issues are problem-solved before the need for a formal complaint. As the office for the organisation is situated at Mandeville Grange, the proprietors are also available should an issue arise. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 26. The Home is well maintained with an evident programme of decoration in place, comfy furnishings, ornaments, T.V., fixtures and fittings are supplied in communal areas, making the environment homely for Service Users. Suitable single and double sleeping accommodation is provided with evidence of personal possessions to make these more homely for Service Users. The Home has designated cleaners, which ensure the Home is clean, hygienic and free from offensive odours. Sufficient numbers of toilets and bathrooms are available to ensure the needs of Service Users are met. The Home has a pleasant garden, which is accessible to Service Users. EVIDENCE: Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 16 The Home is an older building with a newer extension added. A designated handyman/maintenance person is employed by the organisation to ensure any repairs or faults are attended to as soon as is reasonably practicable. There is an evident programme of redecoration in place with areas of the Home identified for ongoing improvements. The Home provides both singe and double bedrooms, which are adequate in size to meet the needs of Service Users. Each bedroom is fitted with sufficient numbers of sockets, call bells and personal lighting to support the individual needs of Service Users. Where necessary, screens are available in shared bedrooms to maintain the privacy of Service Users. Additional adaptations and equipment are provided where necessary. Service Users’ bedrooms are reflective of personal possessions as well as the provided facilities to make these more homely for Service Users. Bedrooms have been fitted with door guards to enable Service Users to leave their doors open. At this time a further 6 door guards have been purchased and will be fitted within the next week. Bathrooms and toilets are scattered throughout the Home within easy access to sleeping accommodation. Specialist baths, hoists and equipment necessary to maintain the safety of Service Users is provided. The Home has a designated domestic team who ensure the home is cleaned to a high standard. On the day of inspection the home was found to be clean and tidy with no offensive odours present. The domestic staff ensure a programme is in place to shampoo carpets regularly to minimise the effects of incontinence, thus ensuring the dignity of Service Users is maintained. Laundry facilities are provided within the Home, an industrial machine with a sluicing facility is available with an industrial dryer also provided. Family members spoken with at the time of inspection were happy with the system in place for the laundering of clothes with Service Users noting the high standards maintained by the Home, especially noted was the laundered bed linen that is provided on a daily basis. The Home’s garden is accessible to Service Users and is regularly used during the summer months. Well maintained lawns and patio areas with suitable garden furniture and an array of flowers provides a relaxing and pleasant area for Service Users to enjoy. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) x EVIDENCE: The Home was sufficiently staffed during the inspection with measures put in place to ensure any sickness or annual leave is covered by either bank or familiar agency staff. Due to the late hour of the inspection, recruitment procedures were not assessed; this will be addressed at the next inspection. Discussion took place with the Deputy Manager in relation to staff training. Staff are receiving regular training to support them in their roles, however this standard was not fully assessed during this inspection. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 38. The Manager has the necessary skills for her role to ensure the practice in the home is in the best interests of Service Users. Individual records were up-to-date and stored appropriately, ensuring the Home are safeguarding Service User information and are working within guidance of the Data Protection Act 1998. The Home undertakes regular monitoring of its health and safety systems to maintain the safety and protection of Service Users and Staff. EVIDENCE: The Home is managed by an efficient and competent manager. At this time the home is unable to fully meet this standard due to the Manager not being enrolled on a management course. The inspector appreciates that the Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 19 Manager has made a decision to retire within the next year and does not expect her to undertake the Registered Managers Award. The Home will need to ensure provision is made for future development of the replacement manager to enable the home to fully meet this standard. The scoring of this standard is not a reflection of the Managers capabilities or management style. Records inspected were found to be maintained to a high standard and were reflective of review. All information in the home is stored appropriately in lockable facilities that are only accessed by staff. All information is held following guidance from the Data Protection Act 1998. Thorough health and safety policies are in place, these were not fully assessed during this inspection, however they have been assessed as standard met at previous inspections. Service Users reported weekly testing of fire alarm systems taking place with all doors using door guards releasing when the bells sound. The home has received Fire Authority visits and in response to their requirements and previous requirements from C.S.C.I. inspections has implemented all improvements. The fitting of the last 6 door guards will further ensure all fire prevention systems are up to standard and in line with current legislation. The home has received a recommendation to ensure they continue monitoring the temperatures of radiators and supply covers to minimise identified risks. The Home provides C.O.S.H.H. data sheets and risk assessments for all cleaning agents used in the Home, these agents were found to be appropriately stored in lockable facilities. Infection control systems are in place to further protect Service Users. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 3 x x x x x 3 Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 21 no 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 Regulation Requirement Timescale for action 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 7 38 Good Practice Recommendations The nursing staff review current regimes such as bathing rotas with Service Users to ensure they are reflective of current wishes and preferences. The home continues to identify radiators which could be a risk to Service Users and ensures covers are provided to minimise the risk. Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 22 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park, Smeaton Close, Aylesbury, Bucks, HP19 8JR 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 Mandeville Grange 20052809 Mandeville Grange X00015 UI Stage 5 S19240 V242881 H53.doc Version 1.40 Page 23 - 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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