Inspection on 20/03/06 for Methodist Homes For The Aged Group

This inspection was carried out on 20th March 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

Methodist Homes For The Aged... 13/01/09

Methodist Homes For The Aged... 10/01/07

Methodist Homes For The Aged... 28/09/05

Methodist Homes For The Aged... 20/09/04

Methodist Homes For The Aged... 06/04/04

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Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Methodist Homes For The Aged Group Epworth Grange 1 Chirmside Street Bury Lancs BL8 2BX Lead Inspector Michelle Haller Unannounced Inspection 09:30 20 March 2006 th 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 Methodist Homes For The Aged Group DS0000008438.V280926.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. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Methodist Homes For The Aged Group Address Epworth Grange 1 Chirmside Street Bury Lancs BL8 2BX 0161 761 7500 0161 763 6630 home.bry@mna.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged 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 Lesley Ann Payne Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 39 service users, to include: Up to 39 service users in the category of OP (Older People). The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 28th September 2005 Date of last inspection Brief Description of the Service: Epworth Grange is owned by a national company called ‘Methodist Homes for the Aged’. The home is purpose built with 5 wings, Elton and Brandlesholme on the ground floor, Seedfield, Walshaw and Ainsworth wings on the first floor. The home is situated near a main road in a residential area approximately one mile from Bury town centre and is close to bus stops and local shops. Epworth Grange is pleasantly sited in its own grounds with surrounding gardens and there is some car parking to the front of the building. The accomodation is provided on two floors in 39 single bedrooms. All bedrooms have an adjoining toilet and sink. A passenger lift provides access to the upper floor. There is a dining room on each wing and each floor is provided with bathrooms. The home also has a large central lounge and an activities room. There is a garden and patio area to the rear of the home that can easily be reached from a ground floor conservatory. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In order to get a balanced and accurate view of this home it is of utmost importance that this report is read in conjunction with the previous inspection report dated 28th September 2005. This inspection was unannounced and was started at 10.05am.It took place on one day and it lasted for about five and a half hours. Time was spent talking to the manager and looking at records. The majority of the day was spent looking around the home, watching what was happening and talking to residents and staff. One member of staff was interviewed in private, and two spoken to as they worked, three service users were spoken to individually and about 5 participated in a group discussion. What the service does well: The home is well run and has a good manager and a willing staff group who get on with the residents and with each other. The home provides opportunity for service users to have a comprehensive assessment completed about their needs prior to or soon after entering the home. The variety and frequency of activities made available to service users at Epworth Grange is excellent. All service users recreational, spiritual and cultural needs are fully catered for and met, whatever their interest and ability. Service users are listened to as individuals and supported, for the most part, in the choices they make concerning everyday living. Service users are also provided with opportunities to make choices and take and keep control of their lives including their finances. The home is well maintained, clean, comfortable and the furnishings, fixtures and fittings provide a homely and pleasant place to live. The home ensures staff employed in the home are suitably vetted and trained to work in residential care. The organisation provides service users with the opportunity to comment on the quality of services within the home. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 6 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. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 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 Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 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 It is the home’s policy to complete a full needs assessment prior to admission to the home. EVIDENCE: It is MHA policy that all potential and prospective residents are subject to a full “domiciliary” assessment in their current place of abode, be this their own home or within another care setting. All residents at Epworth Grange have had such an assessment and these are clearly accessible to approved viewers. The assessments are not currently stored alongside the care plans, which may be where the impression that there are no assessments has arisen. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 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 and 9 The monitoring arrangements that are in place to make sure service users needs are met, must be strengthened and expanded, so that shortfalls in care plans are dealt with effectively. The home’s medication systems are generally satisfactory in ensuring that residents receive medication as prescribed. EVIDENCE: Records indicated and service users confirmed that all routine and the majority of specialist medical checks and treatment were organised by the home. Care plans used by the home would provide good information about how to meet the needs of service users, however, the majority of the six care plans examined had not been completed and so did not present care staff with information to enable them to give a good standard of care. Furthermore, as with the assessments, care plans for certain specialist health or sensory needs were not in place. Care plans that were in place had been, for the most part, reviewed monthly. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 10 The risk assessments for service user who self medicate have been reviewed and promote increased checks of the service users, however this process had not been completed for service users who may administer insulin. It is essential that the home produce risk assessments and checks for service users who self medicate, whatever the route of administration. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 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 and 14 The activities in the home fully meets the needs of all the service users, ensuring that they have the opportunity to lead varied and interesting lives, that promote well being and continued spiritual, emotional and psychological development. Service users are supported in maintaining their independence and exercising choice that promotes their independence and self esteem. EVIDENCE: The home employs an activities coordinator who arranges a variety of activities. All the service users interviewed were keen to acknowledge that the activities and routines in the home gave them the opportunity to be fully occupied. All service users described their favourite activities, which ranged from going out on a one to one basis, painting, gardening, playing the piano, going out for meals, attending concerts to name just a sample of the activities. The activities calendar for the week included morning prayers led by service users, outings to concerts, barge trips, armchair exercises, quiz sessions, cross ward sessions and the running of a club dedicated to the needs of service users with severe short-term memory loss. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 12 During the inspection time was spent in the activities-club room, and approximately 10 service users were observed discussing the days newspapers and enjoying a challenging crossword puzzle. This group were very vocal and stated that the activities in the home were very good. Those who commented confirmed that there were plenty of choices and opportunities to participate in favourite activities such as playing the piano, singing, painting excursions. The activities co-ordinator also runs a club for service users with profound short-term memory loss that concentrates on reminiscence and socialising. During the inspection it was also evident that service users were given the opportunity to go out shopping or attend other activities on an individual, on a one to one basis with staff. There were no complaints about the food, and service users commented that they had particularly enjoyed lunch that day. The meal had been a choice of steak and mushroom pie or spaghetti bolognaise. In addition to staff serving drinks and snacks, each unit has a well-stocked domestic style kitchen and service users were observed preparing themselves drinks and snacks whenever they wanted throughout the day, this facility clearly maximised the independence and autonomy of the services users able to use the kitchen. Comments included ’This is a very good place.’ The routines of the home is flexible and service users and staff confirmed that there were no limits on the choices service users could make in reference to meal times, diet, getting up and going to bed or participating in activities. It was noted however that service users and visitors are not able to leave the home freely due to the fob release system in the home. This was discussed with the manager who confirmed that there was a perceived risk to some service users. The service users right to leave the building without impediment or referral to staff had not been taken into account, and so alternative arrangements concerning front door security should be investigated. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 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): These standards were previously inspected and assessed as meeting the minimum standard. EVIDENCE: Discussion with staff and service users indicated that no adverse changes had taken place in the areas of adult protection or complaints. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 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 and 26 Epworth Grange is well maintained, comfortable and clean, providing service users with an environment that is inviting, homely and pleasant to live in. EVIDENCE: The gardens and outside areas were observed and appeared to be well stocked with flowers and shrubs, providing a lovely view from a number of bedrooms and sitting areas. A tour of the communal and some private areas of the home was undertaken. All rooms that were inspected were clean and free from unpleasant odours. The furniture and fixtures in the home were well maintained and domestic in appearance. It was clear from the contents of bedrooms and other rooms that service users were encouraged to bring their own furniture. Furthermore items too big for bedrooms were used throughout the home and this added to the homeliness of the environment. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 15 The laundry was clean and dry and the washing machine suitable for use in a residential home as it provided sluice and sterilising washing programs. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 16 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): 28 and 29 The home provides staff with adequate and appropriate training to enable them to carry on their work safely. The homes recruitment policies and procedures promote the safety of service users. EVIDENCE: The manger and one member of staff were interviewed and two sets of staff files examined. The manager confirmed that in excess of 50 of care staff have achieved the National Vocational Qualification (NVQ) in care level 2. Furthermore certificates present on staff files and the homes training record also confirmed that a number had also gained accredited awards in first aid and medication training. The staff files examined contained completed application forms, references and evidence of completed criminal record bureaux checks (CRB), and therefore indicated that a thorough recruitment and vetting process had been undertaken. A signed copy of the terms and condition of employment were also in files. The member of staff interviewed was keen to acknowledge that she was aware of Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 17 manner in which to provide service users with support and the actions she would take if she became aware of any issues concerning the welfare of service users. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 35 Service users benefit from, a quality monitoring system managed by the Methodist Homes head office. Service users money and finances are fully accounted for. The accounting system safeguards the service users from exploitation occurring within the home. EVIDENCE: Methodist Homes for the Aged Group completes a quality assurance audit for all their homes. This audit is very comprehensive and completed without reference to the manager or others working in the home. The survey is also anonymous. The outcome of this quality assurance was examined and discussed with the manager. It was clear from the discussion that the outcome of these surveys, were taken seriously and the information analysed by a team in the head-office Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 19 and used to produce an action plan for changes and developments in the home. The manager has also introduced a local service user and relatives questionnaire that is completed with staff. Other opportunities to comment are also provided during staff meetings, service user meetings and meetings for relatives. The home does not support service users in dealing with their benefits or pensions. Each relative or representative gives the service user a set amount of money and if this is to be stored by the home a receipt is given and a counterfoil kept for all transactions. Random checking of two accounts indicated that, as far as could be judged, that service users were appropriately safeguarded against fraud. Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered person must ensure that plan of care is completed so that staff are informed of the actions needed to meet the general and specialist needs of service users. The registered person must ensure that for those residents who self-medicate that the suitability of such an arrangement is risk assessed, monitored and reviewed periodically with records kept. Previous timescale 21/10/05 not fully met. Timescale for action 01/05/06 2. OP9 14 01/05/06 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 Refer to Standard OP14 Good Practice Recommendations The registered person should investigate a means of front door security that allows service users to come and go as they please. DS0000008438.V280926.R01.S.doc Version 5.1 Page 22 Methodist Homes For The Aged Group Methodist Homes For The Aged Group DS0000008438.V280926.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Methodist Homes For The Aged Group DS0000008438.V280926.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. 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!