Inspection on 28/09/05 for Methodist Homes For The Aged Group

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

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

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

Methodist Homes For The Aged... 20/03/06

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 Stuart Horrocks Unannounced Inspection 28th September 2005 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 Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 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.V253463.R01.S.doc Version 5.0 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 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) Methodist Homes for the Aged 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.V253463.R01.S.doc Version 5.0 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. 20th September 2004 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 provide acess 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.V253463.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was started at 9.30am.It took place on one day and it lasted for about five and a half hours. About half of this time was spent talking to the manager and looking at records. The rest of the day was spent looking around the home, watching what was happening and talking to residents and staff. Eight residents and five staff were spoken with. What the service does well: What has improved since the last inspection? The home continues to improve the services and the facilities enjoyed by the residents and their visitors at the home. The manager and the staff have made sure that the things, which needed improving from the last inspection, have been done. The risk assessments that make sure that the residents are safe and properly cared for are better and the Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 Page 6 manager has got more information about how to deal with situations of harm should the need arise 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.V253463.R01.S.doc Version 5.0 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.V253463.R01.S.doc Version 5.0 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): EVIDENCE: The above key standards were not examined at this inspection. They will be checked at the next inspection. Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 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 and 10. Proper arrangements are in place that ensures the residents health care needs are monitored and met. Individual care plans are also in place, which were up to date, regularly reviewed and provided the staff with the information they needed to give a good standard of care. The home’s medication systems are generally satisfactory in ensuring that residents receive medication as prescribed. Care practices in the home ensure that the residents are treated with respect and their privacy and dignity is upheld. EVIDENCE: The care files of four residents were looked at. These contained detailed care plans that had been kept up to date monthly as is required. The care plans are well laid out and they are easy to read and follow. Each plan contained details of health, personal and social care needs for the resident. Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 Page 10 The staff said that they knew each residents needs by reading the care plans, which are readily available to them. Talking to residents, the manager and the staff and looking at records showed that the resident’s health care needs are taken care of and that when necessary health workers such as doctors, nurses and opticians are called. A number of risk assessments are in place; all of these had been reviewed regularly with the information being up to date. Records also showed that the weight of the residents’ is also regularly checked. Suitable equipment is available for the treatment and prevention of pressure sores and the treatment and progress of pressure sores is correctly recorded. Medicines are properly and safely stored. All medicine when given is recorded on the residents’ drug sheets, these records were properly filled in and they were up to date. Those staff that give out medicines have been given the necessary training for this task. A number of residents are responsible for the taking of their own medicines, which they keep safely in their bedrooms. It is commendable that residents are enabled to do this, but the inspector considers it necessary that before residents start to administer their medicines a risk assessment must be done to make sure that the resident is able to do this safely. Checks must also be made to make sure that such residents are taking their medicines as prescribed and a check must also be done periodically to ensure that such residents can continue to safely administer their medicines. Personal support to residents is offered is such a way so as to promote and protect their privacy, dignity and independence. This was confirmed by a number of residents who said that the staff treat them with respect and that their dignity is valued. Those residents spoken with said that the staff were “helpful” and that “they (the staff) talk to us properly”. The staff were seen to deal with the residents in a friendly, comfortable and respectful way. Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 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): 13 and 15. The visiting arrangements are flexible thus enabling residents to have good contact with family and friends as they please. The meals at Epworth Grange are good, offering choice and variety, and catering for individual dietary needs EVIDENCE: From talking with residents and staff the inspector confirmed that the visiting arrangements are flexible with these being described in the resident’s information guide. Those residents spoken with said that they “were free to see their visitors wherever they wanted to”. They described taking visitors to their bedrooms for privacy or seeing them in the main lounge. The residents said that visitors are made welcome and that they (the visitor) can have a warm drink if they so wish. The home uses a four weekly menu that offers a choice of good attractive nourishing food. Warm food is always offered at midday and a warm choice is also often available at teatime. The inspector saw that the midday meal was well presented and looked appetising. The residents were heard to say that the food was “good and Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 Page 12 warm” and they told the inspector that “there is a choice” and that they had “enjoyed the meal”. The home has five small dining rooms that are nicely furnished and they provide a comfortable and homely setting for the residents to eat in. The residents said that drinks and snacks are available at most times and they said, “you only have to ask” (for a drink etc). Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 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 and 19. The home has a clear complaints system ensuring that concerns are speedily dealt with. Protection of vulnerable adults guidance is available and staff training in this topic ensures residents are protected from abuse. EVIDENCE: The home has a Methodist Homes for the Aged leaflet that advises on the steps to be taken when someone wishes to make a complaint and Complaints notices are also displayed around the home. A complaints book is kept which records the details of any complaints made, of any action needed to deal with the complaint and of the final outcome. No complaints have been made to the CSCI since the last inspection (September 2004) but four complaints have been made to the home. All of these have been resolved. The residents spoken with were very clear that they would feel comfortable about raising concerns and that they would “talk to the staff or Lesley (the manager)” if they had any worries. It was clear in discussion with staff that they also knew what steps to take should a resident make a complaint. A number of staff said that if “they couldn’t sort things out at the time” then they would inform the manager about the problem. Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 Page 14 There are written procedures covering adult protection and whistle blowing. Staff members had received instruction in these topics during the home’s comprehensive induction programme and the manager told the inspector that company is about to start further staff training in adult protection. The staff confirmed that they had received such training and they were aware of the different sorts of abuse and they also understood what they should do if they suspected that someone was being abused. Discussion with the manager showed that when incidents arise they are dealt with quickly and properly. A recommendation made at the time of the last inspection was that the home should obtain a copy of the local inter-agency adult protection policy (as an aide to the home’s own policies). This document has now been acquired. Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: The above key standards were not examined at this inspection. They will be checked at the next inspection. However the inspector did spend some time walking around the building whilst talking to residents and staff. The home is decorated and furnished to a good standard and it was seen to be well maintained to both the inside and the outside. Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 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): 27 and 30. Enough staff are provided to make sure that the residents are properly looked after. The staff are properly trained to give the care that the residents need. EVIDENCE: Looking at staff rotas showed that as well as employing care staff, the home also employs domestic, catering and maintenance staff. A worker is also engaged who plans and arranges recreational activities for the residents. Many of the staff team have worked at the home for a considerable time, which ensures that residents are cared for by people they know and are familiar with. Staff morale was good with staff saying that “there is a good atmosphere” and that “we work together well as a group”. The residents said that the staff are “kind”, “happy to help” and that they were “patient and considerate”. On the day of this inspection enough staff were on duty to meet residents care needs. Rotas showed that staff were regularly available in sufficient numbers to ensure that care was properly provided. The staff and the manager said that in their opinion there was enough staff to meet the needs and dependency levels of the residents living at the home. Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 Page 17 The staff were seen to have a natural and comfortable understanding with the residents and they had time to sit and talk with them. Discussion with the staff and the manager showed that there is a strong commitment to staff training within the Methodist Homes for the Aged organisation. Whilst talking with the inspector the staff gave examples of the training that they had been given, this included safe moving and handling, first aid, food hygiene training, NVQ assessment and the care of people with dementia. The provision of this instruction was confirmed when looking at staff training records. New staff are provided with wide-ranging induction to the job training, which takes about six months to complete. Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 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): 31 and 38. The manager is able and experienced and she manages the home well, therefore ensuring that the residents receive a good standard of care. Procedures and practices within the home promote and safeguard the health, safety and welfare of the people living and working in the home. EVIDENCE: The home manager (Mrs L Payne) has been approved and registered by the CSCI and she has considerable experience of working in care settings both in residential and community situations. Mrs Payne is presently doing the NVQ Level 4 Registered Managers Award, which she expects to complete either in December of this year or by January 2006. Discussion showed that Mrs Payne knows the residents and the staff well. Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 Page 19 The home is well run and residents and staff said that Mrs Payne is “easy to talk to” and that she “listens and is approachable”. The home is safely maintained with fire precautions tests done weekly. Looking at records and maintenance certificates showed that these were up to date and the examination of paperwork and conversations with staff also confirmed that they had been provided with the necessary training so that they can work safely. The windows on the upper floors of the home are made in such a way as to stop them being opened too widely thus preventing the risk of accidents. Hot water temperatures at sinks are tested regularly so as to ensure that the water is not too hot. The details of accidents are properly written down and the manager checks these monthly so that she can keep an eye on how many accidents are happening and on who they are happening to. Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No 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 9 Regulation 14 Requirement 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. Timescale for action 21/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Methodist Homes For The Aged Group DS0000008438.V253463.R01.S.doc Version 5.0 Page 22 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.V253463.R01.S.doc Version 5.0 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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