CARE HOMES FOR OLDER PEOPLE
The Grange Grange Road Northway Tewkesbury Glos, GL20 8HQ Lead Inspector
Ruth Wilcox Unannounced 10 August 2005 08:45 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. The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service The Grange Address Grange Road 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) 01684 850111 01684 290221 CTCH Ltd Mrs Chris Martin Care Home with Nursing 69 Category(ies) of Old Age not falling within any other category registration, with number (69) of places The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 17 May 2005 Brief Description of the Service: The Grange is a purpose built care home that has been extended over the years to provide residential and nursing care for sixty-nine older people over the age of 65 years. It is owned and managed by the C.T.C.H Ltd group of homes. It is situated in the residential area of Northway, in Tewkesbury. There is a small shopping precinct nearby and a Public House. The home has car parking spaces to the front and rear of the building, with a small-enclosed garden running alongside the home and a courtyard garden. The accommodation is set out on three floors, which are accessed by stairs or a shaft lift. Bedrooms are single with en-suite facilities, but there are a few rooms that can be used as double bedrooms if couples wish to be accommodated. Assisted bathing and showering facilities are provided, and there are several lounges, dining areas and other quiet sitting areas. The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One inspector conducted this unannounced inspection over five and a half hours on one day in August. The findings of an additional visit, conducted in May 2005, also contributed to this inspection. Six staff were spoken to, and sixteen residents and two visitors were spoken to in order to establish their views about the care and services they receive. The care of five residents was looked at particularly closely. Care records were inspected, as were the systems for the provision and recruitment of staff, their supervision and direction. The standard of meals, and the opportunities for social activities for the residents were inspected. A tour of the premises took place, with particular attention to the standard of maintenance and environmental safety issues. The procedures for addressing complaints and concerns if they arise were also looked at. Staff were observed going about their duties whilst interacting with the residents. The home was very welcoming, and staff were fully open and cooperative with the inspection process. What the service does well:
The home provides a welcoming and comfortable environment for the residents and visitors. An administrator is in the entrance hall, and this proves a great asset in terms of providing a welcome to people, and in terms of accessibility for support and advice. Residents are admitted to the home following a complete assessment of their personal and health needs. Care plans are written individually on the basis of the assessment, and those recorded for nursing clients are well written and informative, and give staff clear direction for meeting residents’ needs. There is good access to all health care services for all residents. There is a cohesive staff group in this home, with a good degree of success recently in recruiting to compliment the team. There appears to be very positive relationships between the residents and staff, with staff being aware of residents’ needs and preferences.
The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 6 There is a good standard of food provided here, with residents confirming the quality, quantity, variety and choice available to them. There are lots of opportunities for social activities, with a wide-ranging and varied programme in which residents can participate or not, according to their personal choice. What has improved since the last inspection? What they could do better:
Although many aspects of the residential care plans are properly recorded, there are some parts that could be improved by staff recording in fuller detail and making sure that all risk assessment work is directly linked to a care plan. Generally the residents speak very positively about the way their care is delivered, and about the relationships they share with staff. However there were isolated indications that a very small minority of staff were less receptive than others to them, the result of which could compromise their dignity.
The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 7 There were some maintenance issues that had not been satisfactorily addressed, and these included the provision of a sluicing disinfector and radiator safety guards. It was agreed that the disinfector would be provided by the end of May 2005, and though this has been purchased, it has not been installed and is unusable. It was also agreed that radiator guards would be fitted by the end of July 2005, but this has not been done; however indications are that this work is to be commenced during the same week of this inspection. Work to make hot water temperatures safer for residents is due to be completed by the end of this year. Some management issues are being addressed separately to this inspection report. 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. The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.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 The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.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) 3. The home’s admission procedure ensures that all residents are admitted on the basis of a full assessment of their needs, ensuring that they can receive the care that they require. EVIDENCE: Residents are admitted to the home on the basis of a fully documented assessment of their health and personal needs. The assessment tool used for the four most recent admissions was seen to be comprehensive; they had been conducted in advance of the admission, and had been done either in hospital or the person’s previous care home, as had been appropriate at the time. The Grange does not provide intermediate care. The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.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 & 10. There is a care planning system in place, which in the main provides staff with the information they need to satisfactorily meet residents’ health and personal needs; additional recording in some cases would further enhance this. Care and support is offered in such a way as to promote the privacy and dignity of the individual. EVIDENCE: Residents have a personal plan of care, which is directly linked to their needs assessment; five plans were chosen as part of a case tracking exercise. Care plans in the main are well written, with clear instructions for staff to follow. Staff in the residential unit complete the plans for those residents accommodated there, and nursing staff complete the plans for the nursing clients. In the residential unit the assessment and care plan information is combined together in one section. Additional risk assessments also form the basis for care planning, although in one case a pressure sore assessment showed that the person was very slightly at risk of developing a sore. There was no plan of
The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 11 care to address this, though other recording showed that the pressure areas were healthy and intact. In two cases a falls risk assessment showed a risk of falls; although there was a care plan in place to address this in part, there was no information about how staff were to monitor or advise (if possible) these people. One person had been attending an ulcer clinic; daily records showed that it was imperative that this person wore prescribed leg stockings. On case tracking this person, they were evidently wearing them as prescribed, but this information did not feature in any plan of care. One person had a supra-pubic catheter; there was no specific plan of care for managing this, or for the cleaning and hygiene of the actual site, which daily records indicated was sore. The nursing care plans were well written and informative, with care plans directly linked to all assessments, including risk assessments. In one particular case, the resident could apparently display some aggression, and though there was a care plan to manage this in part, the community psychiatric services did not form part of that plan, despite them having some occasional involvement. All records showed a wide range of health care services being sourced to support the care being given by the home, with visiting external health care professionals performing assessments, reviews and treatments. Staff spoke of ever increasing resident dependency levels, and their attempts to get new assessments from the appropriate external sources in order to review individual circumstances. It was reported that responses to this are extremely slow from external agencies, and that staff work tirelessly to continue to meet residents’ needs. A district nurse, who was visiting the home on this day, indicated that a lot of health related referrals are made from the residential unit, and sometimes from the nursing unit. Referrals from the nursing unit are the subject of some review, as nursing staff recognise the need to acquire additional skills in some areas, rather than refer to the district nurse. Case tracking confirmed that all planned care was being carried out appropriately, even in isolated cases reported above, where written plans could have shown it in more detail. Residents were generally satisfied with the care they were receiving, saying that staff were helpful, and looked after them very well. One person said that a ‘neighbouring’ resident was keeping her awake at night, as they could be noisy. Another person indicated that one particular member of staff could be rude on occasions, and after discussion with the inspector agreed that they would discuss this with the deputy manager. Staff were observed going about their duties interacting with the residents, and were seen to be attentive and respectful.
The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 12 The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 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 standard(s) 12 & 15. An activities and entertainments programme is offered, in order that residents are provided with regular and varied opportunities for social activity. Dietary needs of residents are well catered for, with a balanced and varied selection of food available that meets their tastes and choices. EVIDENCE: There is a regular programme of social opportunities for residents, with records kept of activities held. Records showed a variety of activities, to suit many tastes and preferences. In addition to games, music, parties, exercises and entertainments, important calendar dates and festivals are always observed with celebrations, decorations and special menus. The home should be commended for their efforts in this regard. The home tries to include all residents in such activities, but has no record of those participating or of preferences identified on the basis of a consultation; despite this residents indicated that their choices are respected regarding their participation or not. Menus contain a range of varied and nutritious meals available for residents. A list of individuals’ choices is devised daily, and the cook prepares meals on this basis; residents said that there was a lot of choice and variety available to them.
The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 14 The lunchtime meal looked wholesome and appetising, and residents confirmed their enjoyment of it, with some saying it was ‘very good’, and that they ‘always enjoyed their food’. The meal was served in the different dining rooms, and was well presented. Staff were providing assistance where necessary in a sensitive and discreet manner. The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 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 standard(s) 16. The home has a satisfactory complaints system, with evidence that residents feel that any concerns they may have are listened to and acted upon. EVIDENCE: The written Complaints procedure was displayed on the public notice board, and is also issued as part of the service user guide. Residents confirmed that staff would listen to them if they had any concerns, and that they felt able to raise them. One person said that most staff were receptive, but that the ‘one or two were less so’. There have not been any recent complaints, and there were no records to inspect. The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 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 standard(s) 19 & 25. The standard of the environment in this home is generally good, providing residents with a comfortable place to live; however a delay to address some maintenance improvements could compromise the health and safety of those living in the home. EVIDENCE: Maintenance staff are employed, and areas for attention are identified in a regular audit of the premises. The home is generally well and safely maintained and decorated, though some areas have not been redecorated for some time now. The maintenance person was present carrying out some minor works on the day of this inspection. An additional inspection visit earlier this year confirmed that good progress was being made to address some maintenance requirements. This included the hygienic refurbishment of some metal frame beds, the provision of additional linen and the provision of a sluicing disinfector. However, despite the
The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 17 disinfector being delivered within the designated timescale, it has not yet been fitted and cannot be used. The Proprietor has confirmed that hot water is stored at appropriate temperatures for the control of Legionella. It has been agreed that work to blend hot water at the outlets to ensure a safer temperature for the residents will be completed by the end of this year; this work has so far not begun. It was also agreed that radiator guards would be installed for the protection of residents by the end of July 2005. This has not been carried out within the designated timescale, though it was reported that the guards have been delivered with work about to commence. Documented risk assessments for each of these areas have been carried out on each resident to identify where any risks might be in the meantime. The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 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 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) 29. The recruitment practices are improving, with appropriate checks being carried out, so that residents are not placed at risk. EVIDENCE: The records of four recently recruited staff were selected for close inspection. In the main records contained all of the required documentation and preemployment checks, with the following exceptions: • One applicant had not signed a criminal convictions declaration • Two applicants had not provided a sufficiently detailed employment history, and despite having previously worked with vulnerable adults, there was no written explanation of the reasons why they had left that employment. (Written references from a past employer however, were good) There were records of interviews for two of the applicants. The home has recently reviewed its entire recruitment policy, in order that it fully complies with all the statutory requirements. This includes the updating of applications and reference request letters, in order to facilitate the easier capture of the required information. The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 19 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) 32, 33 & 36. The staff have a very good understanding of the residents’ support needs, and this is evident from the positive relationships, which have been formed between the staff and residents. The home regularly reviews aspects of its performance through a programme of self-review and consultations, which includes seeking the views of the residents. The arrangements for staff supervision, if applied consistently, would ensure a more common understanding among the staff for the benefit of the residents. EVIDENCE: There are occasional staff meetings, and recorded minutes of these were seen. These minutes demonstrate that staff have the opportunity to raise and discuss concerns. The manager and her deputy are accessible in the home, with staff and visitors indicating that there is a good deal of confidence in the deputy in particular.
The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 20 There are plans for a monthly ‘working lunch’ between the senior staff in the interests of cohesiveness and communication, and for the manager and senior staff to work together on a shift, ‘hands on’ with the residents, to obtain an understanding of what the care staff face when working with residents. The deputy manager said that management endeavours to be as open as possible with staff, and that staff do approach the Group Care Manager as well. Certain management issues, and subsequent impacts on staff are the subject of letters to the Provider separate to this inspection. Resident meetings are not routinely held, though opportunities to share information on a more informal and intimate basis are regularly available. Staff were observed on this day to share very inclusive and positive relationships with the residents. The home has a very accessible administrator/receptionist, who is well trained and skilled, and who is a great asset to the home in terms of presenting an open and welcoming atmosphere for the home. There are a number of quality assurance monitoring methods conducted or planned here, which includes resident and visitor satisfaction surveys, and internal audits on the environment, including the standards of hygiene and cleanliness. CTCH Ltd is also introducing a series of self-audit assessment tools into the home, which will assess the home’s performance in specific areas relating to the National Minimum Standards. Some progress has been made regarding the implementation of a formally recorded staff supervision programme. A matrix has been devised to monitor the programme, and judging from this the home is not going to reach the target of six supervision sessions in the twelve month period. Some random supervision records were seen, and the content of some of these was not based on practice and professional developmental issues, as is recommended. The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 1 x x x x x 1 x STAFFING Standard No Score 27 x 28 x 29 2 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 x 2 3 x x 2 x x The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15(1) Requirement The Registered Manager must ensure that staff prepare written care plans, which demonstrate the care needed for vulnerable pressure areas in cases identified on risk assessment. (previous timescale of 31/3/05 not met in full) The Registered Manager must ensure that care plans are consistently prepared, which demonstrate how residents needs, in respect of their health and welfare are to be met. (This is with particular reference to a supra-pubic catheter on this occasion) The Registered Manager must ensure that plans are recorded, which relate to specialist health care. (This is with reference to a clinicians directives and the community psychiatric services) The Registered Manager must ensure that all staff conduct themselves in a manner that respects the dignity of residents. The Registered Person must ensure the provision of a sluicing disinfector (previous timescale of Timescale for action 30/9/05 2. 7 15(1) 30/9/05 3. 7 17(1.a) Schedule 3. 30/9/05 4. 10 12(4.a) 30/9/05 5. 19 23(2.k) 30/11/05 The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 23 6. 25 13(4.c) 7. 29 19 (1.bi) Schedule 2. 30/5/05 not met in terms of it being fit for use). The Registered Proprietor must 31/10/05 ensure that low surface temperature safety features are provided for all radiators accessible to residents. (previous timescale of 31/7/05 not met) When recruiting staff the 30/9/05 Registered Manager must obtain: Details of criminal offences a) of which the person has been convicted, including details of any convictions which are spent b) in respect of which he/she has been cautioned by a constable. A full employment history with satisfactory written explanation of reasons for gaps in employment. Written verification of the reason why the person ceased to work in their last position (if it involved contact with vulnerable adults). 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. 4. Refer to Standard 7 12 29 36 Good Practice Recommendations Care plans devised on the basis of a falls risk assessment should contain reference to resident monitoring arrangements. Staff should keep a record of residents choices for social activities, and of those participating. A record of interviews held with all prospective workers should be kept. Formal staff supervision should be given at least six times each year, and should include aspects of practice issues,
D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 24 The Grange philosophy of care and career development needs. The Grange D51_D03_s16608_The Grange_v237886_020805_Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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