CARE HOMES FOR OLDER PEOPLE
Scarsdale Grange Nursing Home 139 Derbyshire Lane Sheffield South Yorkshire S8 5EQ Lead Inspector
Janis Robinson Unannounced Inspection 17th January 2006 9:00 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 Scarsdale Grange Nursing Home DS0000021804.V274438.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. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Scarsdale Grange Nursing Home Address 139 Derbyshire Lane Sheffield South Yorkshire S8 5EQ 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) 0114 258 3534 0114 258 0828 Mr John Martin Foster Mrs Elaine Pearl Adams Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Three service users aged 60 years and over may be accommodated at the home. 17th May 2005 Date of last inspection Brief Description of the Service: Scarsdale Grange is a purpose built home, providing care for up to 40 older people, some of whom require nursing care. The home is in a residential area of Sheffield, with good access to public services and amenities, such as public transport, shops and public houses. The home has two floors, accessed by a passenger lift. Each floor has communal lounge, dining rooms and bathing facilities. All of the bedrooms are single, each with en-suite toilet facilities. The home has gardens and a car park. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 4.5 hours from 9.00 am to 1:30 pm. An inspection of a proportion of the environment was undertaken. Records were examined, including: care plans, complaints, staff recruitment and training, menu and fire records. Interactions between staff and residents were observed. The inspector spoke with a proportion of the staff on duty, and 8 residents. Discussions with the homes manager and administrator also took place. What the service does well: What has improved since the last inspection?
Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 6 A written menu for lunchtime meals had been developed, to inform residents of their choices. The ground floor corridor and dining room had been redecorated and recarpeted. A rolling programme to replace bedroom furniture, bed linen and curtains had commenced, to improve the environment. Some new dining chairs had been provided. The gardens had been landscaped, to provide residents with a better view. A stand aid hoist had been purchased to meet residents’ personal care needs. A weekly programme to check and service wheelchairs had been introduced, to ensure residents were moved safely. Staff had been reminded how to access the homes complaints procedure and record complaints. Complaints forms had been made available to staff. A formal system for staff supervision had commenced, to develop and support staff. Staff recruitment files contained proof of identification. Fire records evidenced that equipment was checked at weekly intervals to ensure they were in working order. What they could do better:
A statement of purpose and service user guide was on display in the home. The service user guide required reviewing to ensure it contained up to date information. Copies of the guide had not been provided to residents or their representatives to give them information about the home. Whilst individual care plans were in place, not all contained information on the residents wishes regarding dying and death, to ensure these were carried out. Since the last inspection a written menu had been introduced, however, this only recorded the lunchtime meal. The menu required expanding to give residents information on the full choice of food available. The homes complaints record did not detail the action taken or outcome of the complaint. Complaints records required organising to improve access to information and monitoring. A thorough recruitment procedure to ensure residents’ safety was upheld was not consistently adhered to. One staff record did not evidence that gaps in employment history had been explored. A reference from the most previous employer had not been obtained. Only one written reference, as opposed to the required two, had not been obtained. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 7 A staff training plan and individual training records had not been developed. The chart of staff training did not include all mandatory training. Some staff required updates in food hygiene training. Records of fire drills did not contain sufficient detail. Some cleaning substances were insecurely stored. 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. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 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 the following standard(s): 1, 3, 4 and 5. Standard 6 does not apply to this home. Whilst the home had a service user guide, copies had not been provided to individual residents and their representatives. Some information in the guide was out of date. Assessments prior to admission took place. Trial visits to the home were encouraged, to enable prospective residents and their relatives to make informed choices. EVIDENCE: A service user guide was on display in the entrance area. Copies had not been provided to individual residents and their representatives to give them detailed information about the home, and inform them of their rights and choices. Assessments were undertaken prior to admission to ensure the home could meet prospective residents needs. These were carried out by the homes manager or qualified staff. Copies of care management assessments were obtained, where available, to give staff at the home full information. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 10 Staff undertook periodic training to keep them up to date, and could give examples of good practice. Staff spoken with had caring attitudes. Access to specialist services, such as chiropody, opticians and dentists was provided to ensure residents individual needs were met and supported. The residents spoken with said they, or their relative, had been able to look around the home prior to admission. The residents spoken with said the staff cared for them well. All of the residents said their needs were well met, and they were `very happy’ with the care provided. All residents were well groomed and appropriately dressed. The manager confirmed that where residents’ condition changed and deteriorated, and staff felt unable to meet assessed needs, referrals to specialists and relevant professionals such as psychiatric services, would be made. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Each resident had a care plan, to ensure his or her opinions had been sought and needs assessed. These provided staff with the information needed to fully care for individuals. Health care needs were monitored and met. Systems were in place to safely store and administer medication. Resident’s privacy and dignity was respected. Care plans did not contain information relating to residents wishes regarding dying and death. EVIDENCE: Two care plans were inspected. These contained specific information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. The residents had signed their plans. Residents spoken with were aware of their right to access their records, but chose not to do so. The plans contained detail of all health care contacts, appointments and treatments, and the home supported access to these to ensure health was maintained. Accidents wee recorded and monitored. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 12 A pharmacist audited the medication systems. Each resident had a medication profile, to inform staff. Medication was stored and administered in line with safe working practices. Medication administration records were fully recorded and up to date. Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and residents appeared respectful and caring. Residents spoken to felt ‘well looked after’. Care plans did not record any wishes regarding dying and death. These must be sought to ensure they are carried out. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents were able to make choices about how they spent their time. A range of activities were offered to residents, to improve choices and maintain interests. The home had an open visiting policy, in order to develop and maintain good relationships with residents’ representatives. A varied diet was provided. The homes menu did not detail all meals provided. EVIDENCE: Residents said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. An activities worker was employed, to provide a range of appropriate social opportunities both in and outside of the home. Residents were free to join in any organised activities. All of the residents spoken with said they enjoyed the range of activities offered, and said enough were provided. Several residents were looking forward to the weekly drinks and singing activity that was taking place the afternoon of the inspection. Residents confirmed that they were able to see their visitors in private. One resident spoken said that a relative visited them every day. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 14 A written menu had been provided to residents, to inform them of their choices. However, this only detailed the lunchtime meal. All meals must be recorded on the menu to give residents full information regarding the food available to them. Staff were observed offering assistance with eating to those residents that required this support. All of the staff and residents spoken with said that choices were offered at mealtimes, and staff had access to food at all times to cater for residents needs. Bedrooms contained a range of personal possessions, enabling residents to make their room comfortable and homely. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 15 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 18. The home had a clear and accessible complaints procedure, to ensure residents’ rights were protected and any concerns listened to and taken seriously. The homes complaints record required some addition to ensure all relevant detail was recorded. Staff were aware of the homes system to record complaints. An adult protection procedure was in place, to ensure residents safety was promoted. All staff had not undertaken training in adult protection. EVIDENCE: The homes complaints policy was on display in the entrance area of the home. It contained relevant information and informed the reader who to contact external to the home, should the complainant wish to do so. The homes record of complaints was not well organised, as a consequence information was difficult to obtain. The complaints record would benefit from reorganisation in order that complaints can be monitored efficiently and information more easily retrieved. The form used to record complaints did not detail the action taken or the outcome of the complaint. Staff had been made aware of the form to use to record complaints, to ensure all relevant information had been sought. A supply of forms had been made available to staff so that they could access these when needed. The homes adult protection policy included information on local procedures. Staff had not been provided with training to ensure residents were safe, and to inform staff of the procedures to follow if an allegation was made.
Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 16 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, 20, 21, 22, 24, 25 and 26. The home was clean and well maintained. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and residents’ bedrooms were well decorated and personalised. Sufficient bathing facilities were provided. One bathroom was used as storage. The home was free from odours. A central laundry and central kitchen served the home. A rolling replacement programme to renew bedroom furniture had commenced. Marked carpets had been replaced. An additional hoist had been purchased. The gardens had been landscaped. EVIDENCE: The environment was clean and free from odours. Communal areas appeared comfortable and were well decorated. Sufficient bathing facilities were available to meet the personal care needs of residents. A stand aid hoist had been provided to fully meet residents moving and handling needs. A rolling programme had commenced to replace bedroom furniture that was worn, and
Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 17 replace bed linen and curtains. Four bedrooms had benefited from this. A further two bedrooms every three months were planned to be updated. Sufficient bathing facilities were provided. A stand aid had been purchased to better meet the moving and handling needs of residents. One bathroom was used to store a commode, a table and a box of sundry items. A system had been introduced to maintain wheelchairs. These were checked and serviced on a weekly basis. No residents were moved in wheelchairs without footplates in place unless a written risk assessment had been undertaken. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Agreed levels of staff were being maintained. Some staff undertook NVQ training. Recommended levels of NVQ trained staff had not been achieved. The homes recruitment practices, to ensure a thorough procedure was in operation, needed improvement. Staff undertook periodic training to keep them up to date. A staff training plan and individual training records had not been undertaken. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained to meet the needs of residents. Residents spoken with felt that enough staff were provided. Of the 31 care staff, 7 staff had achieved NVQ level 2 in care, a further 4 staff were undertaking the training. Whilst this is an improvement, the numbers of NVQ trained staff did not meet the recommended 50 of the care staff trained to NVQ level 2 in care by 2005, to ensure the staff team was qualified and competent to carry out their duties. Two staff files were inspected. Proof of identity and CRB disclosures were included in the files. One file contained one written reference, which was not from the last employer. Gaps in employment history had not been explored. Two written references, including one from the previous employer, must be obtained for all staff being recruited to ensure safe procedures are followed. The form used to track applications had not been completed in one file inspected.
Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 19 Whilst a chart of staff training was in place, individual training records, and a training plan had not been developed to ensure staff undertook all relevant training. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 20 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, 32, 35, 36, 37 and 38. The manager’s leadership approach benefited residents and staff. Residents’ monies were safely managed. Formal staff supervision to develop and support staff, had been introduced. The homes records were stored securely, to respect residents’ rights. Fire systems were checked at the required frequency. Records of staff fire training did not contain the required detail. Some staff mandatory training had not been provided, posing a potential risk. Some cleaning substances were insecurely stored. EVIDENCE: All of the staff spoken with said the manager was approachable and supportive. The manager was a qualified nurse. She was undertaking NVQ 4 in management. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 21 Residents’ monies were securely stored. Records evidenced that credits and debits were recorded, and receipts retained. Amounts of monies kept tallied with the records. Staff supervision, to develop, inform and support staff, had been introduced. Staff confirmed that they had undertaken fire training and participated in a drill within the recommended timescales. However, fire drill records did not contain all of the required information to ensure safe practices were promoted. Records of mandatory training did not include all aspects of training. Some staff required refresher training in food hygiene, in order to maintain safe standards. Fire equipment was checked on a weekly basis. Some cleaning equipment was insecurely stored, posing a potential hazard. This was moved to secure storage during the inspection to ensure residents were safe. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 22 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 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 2 3 X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 2 2 Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 23 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 OP1 Regulation 4 Requirement Timescale for action 30/04/06 2 OP11 15 3 4 OP15 OP16 12 22 The service user guide must be updated to ensure all of the information included is up to date. Copies of the guide must be provided to current and prospective residents. Residents’ wishes regarding 31/03/06 dying and death must be sought and recorded in their care plan. (Previous timescale of 01/08/05 not met) The menu must be expanded to 30/04/06 include all meals provided. The outcomes of complaints 31/03/06 must be recorded and detail whether the complainant was satisfied. (Previous timescales of 01/03/05 and 01/08/05 not met) The homes pro-forma to record complaints received must be expanded to include action taken and outcomes. All staff must be trained adult protection procedures. (Previous timescales of 01/04/05 and 01/08/05 not met) Bathrooms must not be used as storage.
DS0000021804.V274438.R01.S.doc 5 OP18 18 30/04/06 6 OP21 12 31/03/06 Scarsdale Grange Nursing Home Version 5.1 Page 24 7 OP29 19 A thorough recruitment procedure must be in operation. Two written references, one of which must be from the last employer, must be obtained prior to commencement of employment. All gaps in employment history must be explored. The recruitment checklist contained in staff files must be fully completed. A staff-training plan, which meets the National Training Organisation workforce training targets must be developed. Individual training profiles must be kept. (Previous timescales of 01/04/05 and 01/09/05 not met.) This requirement has been outstanding since June 2003) All staff must receive statutory training, records must be accessible and organised so that information can be easily retrieved. (Previous timescales of 01/03/05 and 01/09/05 not met) All records required must be available for inspection. These must be kept up to date, well organised, and monitored. (Previous timescale of 01/09/05 not met) All staff must undertake food hygiene training. (Previous timescale of 01/11/05 not met) An audit of staff mandatory training must take place. Where gaps are identified, training must be provided. Fire drill records must be expanded to include all of the required information, including: The date and time of the drill,
DS0000021804.V274438.R01.S.doc 17/01/06 8 9 OP29 OP30 12 18 31/03/06 31/03/06 10 OP37 17 01/09/05 11 12 OP38 OP38 18 18 01/11/05 30/04/06 13 OP38 12 30/04/06 Scarsdale Grange Nursing Home Version 5.1 Page 25 14 OP38 13 The full names of the staff participating in the drill, and The nature of the drill. All substances that may be hazardous to health must be securely stored at all times. 17/01/06 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. 2. 3 Refer to Standard OP28 OP31 OP38 Good Practice Recommendations 50 of the care staff should be trained to NVQ level 2 in care. The manager should be trained to NVQ level 4 in management. A mandatory training matrix should be developed. Scarsdale Grange Nursing Home DS0000021804.V274438.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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