Inspection on 10/09/07 for The Grange

This inspection was carried out on 10th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

The Grange 04/03/09

The Grange 07/02/08

The Grange 23/01/06

The Grange 10/08/05

The Grange 15/02/05

The Grange 14/09/04

The Grange 01/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Grange Grange Road Northway Tewkesbury Glos GL20 8HQ Lead Inspector Mrs Ruth Wilcox Key Unannounced Inspection 09:00 10th & 11 September 2007 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 The Grange DS0000016608.V344911.R01.S.doc Version 5.2 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. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Grange Address Grange Road Northway Tewkesbury Glos GL20 8HQ 01684 850111 01684 290221 debbie@ctch.co.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) CTCH Ltd Mrs Chris Martin Care Home 69 Category(ies) of Old age, not falling within any other category registration, with number (69) of places The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate a named service user who is 63 years of age Date of last inspection 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. Information about the home is available in the Service User Guide, which is issued to prospective residents, and a copy of the most recent CSCI report is available in the home for anyone to read. The weekly charges for The Grange range from the basic local authority rate of £357.90, up to £520.00, plus any Registered Nurse Care Contributions payable. Optical services, Chiropody, Hairdressing, Newspapers, and Toiletries are charged at individual extra costs. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. Two inspectors carried out this unannounced inspection over two days in September 2007. A check was made against the number of requirements that were issued following the last inspection, in order to establish whether the home had ensured compliance in the relevant areas. Care records were inspected, with the care of six residents being closely looked at in particular. The management of residents’ medications was inspected. A number of residents were spoken to directly in order to gauge their views and experiences of the services and care provided at The Grange. Some of the staff were interviewed. Survey forms were also issued to a large number of residents and visitors to complete and return to CSCI if they wished; no responses were received from residents and only three were received from visitors and relatives. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service and the policies for protecting the rights of vulnerable residents were inspected. The circumstances in relation to a recent complaint received by CSCI were also considered in detail as part of this inspection. The arrangements for the recruitment, training and provision of staff were inspected, as was the overall management of the home. A tour of the premises took place, with particular attention to health and safety issues, the maintenance and the cleanliness of the premises. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home manager has undergone training in the recently implemented Mental Capacity Act, and there are plans to cascade this training to all other staff as soon as possible. A bathroom has now been refurbished, as was required, with the provision of a new assisted bath and new non-slip flooring. One of the stair carpets has been in very poor condition for some time, and this is now being replaced, with redecoration of the stairwell taking place also. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 7 What they could do better: The manner in which assessments for prospective residents at The Grange has been conducted has been inconsistent, with recorded outcomes minimal or completely absent in some cases. Many aspects of the subsequent care plan documentation are also poorly completed, with care plans not drafted at all to meet some of the identified needs; repeated failures were identified in this area. Although some good examples of care planning and care practice were observed, the failures in this area are significant enough to be affecting the standard of care being delivered to some residents. The systems for managing residents’ medication are mostly satisfactory, however certain unexplained discrepancies were identified on this occasion, which must now be investigated in an effort to explain them. There is some evidence from listening to residents, staff and an external stakeholder who has raised concerns about this home, that there is some reluctance to raise concerns or complaints here, and that if they do they are not always taken seriously and addressed properly. Some of the residents said that they felt happier discussing their concerns with the home’s administrator rather than the manager. It is because of such circumstances that an external stakeholder raised a formal complaint with CSCI regarding care issue concerns to which they could not obtain a satisfactory response from the home. The detail and outcomes of this complaint feature throughout the body of this report, and breaches of regulations were identified in this case. The home’s policies and procedures in relation to the protection of the vulnerable residents living here have not been strictly adhered to; this is specifically in relation to disciplinary actions taken with staff whose level of performance and practice had been deemed to be abusive to residents. There has not been the necessary transparency and sharing of information that would be required with other agencies and CSCI. The condition of the environment is deteriorating in places, with a number of areas appearing well worn and fatigued; some pieces of equipment were not very clean, and a statutory requirement in this area had to be repeated. Residents do not always experience an acceptable laundry service. The laundry is extremely busy, and there are ongoing maintenance issues in there, which are contributing to the problems and delays with the service. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 8 The recruitment procedures for new staff are still not being observed in full, with a repeated failure to carry out all of the required pre-employment checks. There are instances of when induction training for new staff has not been delivered within an acceptable time frame. This has resulted in new staff working with residents, and becoming involved in certain procedures before they are properly trained. There have been a number of occurrences that could have adversely affected the wellbeing of the residents, which should have been reported to CSCI as required under the Care Home Regulations. The manager has failed to act appropriately as required on a number of occasions. In consideration of the numerous shortfalls and failures identified in this home a much more rigorous quality monitoring process is required. 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 summary of this inspection report can be made available in other formats on request. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 9 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 The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all people living in this home are assessed fully prior to their admission, meaning that they cannot be assured completely that the home will be able to meet their needs. EVIDENCE: Although the home’s Statement of Purpose was not inspected in detail on this occasion, advice was given that it will now require a slight amendment to demonstrate the fact that the home is providing care and accommodation to a resident who is under 65 years of age. Pre-admission assessment forms for six residents were inspected, most of which appeared to have essentially been carried out prior to the person’s admission to the home. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 11 However, most contained very limited information, with the format for recording viewed as being quite restrictive for the assessor; this is an issue that has already been identified by the home as an area for improvement. The recorded information did not provide a clear enough picture of all the person’s needs, and this was particularly so in relation to one case, which was being considered as part of the complaint indicated in the summarised methodology of this inspection, and which will feature throughout this report. This person evidently had some mental health needs, which had not been considered or recorded during the assessment process. Furthermore in this particular case, the person conducting the assessment had attached a note to the assessment form requesting that someone in the home ‘fill in any gaps’ she had left on the assessment form. This has to lead to the conclusion that this assessment had definitely not been carried out appropriately, certainly in the pre-admission stage. The Grange does not provide intermediate care. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People living in this home are being placed at risk from unsafe management of health and care issues through unclear care planning, and some isolated medication anomalies. EVIDENCE: Residents have their own plan of care, six of which were inspected in closer detail as part of the case tracking exercise. Three of these were particularly relevant to the complaint that had been raised, and which was being considered as part of this visit. In some cases there was appropriately recorded care planning on the basis of the assessments that had been carried out. Some good examples of this included planning for the management of a PEG (Percutaneous Endoscopic Gastrostomy) feeding regime, planning to manage someone’s particular behaviour disturbances, and hygiene needs, although some were not viewed as being particularly person-centred. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 13 Records demonstrated the involvement of health care services as appropriate, which included the Optician, Chiropodist, Doctors, Dietician, Community Nursing Team, ‘Over 75 year’ medical checks and Registered Nurse Care assessments. There were certainly examples seen whereby care was being delivered in accordance with that which was identified on assessment and in care plans. However, there were very significant gaps and omissions in this regard, not only in care planning itself, but also in the affect this was having on staff practices. In one case, the resident was discovered to be a diabetic; this fact did not feature in the original assessment, although a list of medications at the point of admission does indicate that this condition had already been diagnosed. Blood glucose monitoring was carried out in a haphazard fashion, and there was no recorded plan of care to manage this particular need. In another case, the person had diabetes and needed some wound management; neither of these factors featured in care planning. Another person had been assessed in the Ulcer Clinic, was receiving care to wounds, and required the application of compression stockings each day, and that she rest with her legs in an elevated position; there was no recorded plan of care to address these points. Assessments for pressure sore vulnerability were recorded, although many of these were not accurate, with scores appearing incorrect, resulting in too low a risk factor being identified. These assessments had been regularly reviewed to some degree, but had not been reassessed as part of this, with scoring and risk factors remaining incorrect and out of date. In one case the assessment recorded that there were ‘broken spots’ on the skin, with review entries saying that ‘skin was intact’. In another case the assessment did not reflect the fact that the person’s mobility had seriously declined, and went on to say that her ‘skin was intact’, when in fact she was having regular dressings to wounds. In some cases there was no recorded care planning to address the risks posed to people of developing pressure sores; in at least one case there was no support equipment in place either, although this person did not have any pressure sores at this time. Manual handling risk assessments were recorded, and each had an associated care plan. In one case the fact that the person was partially sighted had not been taken into account, and in another that the person had a significant confusional condition, both of which could be significant factors with manual handling. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 14 Falls risk assessments were in place for some, but were missing for others for whom there was a history of falls. In at least one case where the person was assessed as being at high risk of falling, reviews were extremely limited, with no mention or appropriate adjustments to account for the fact that they had suffered three falls in the past month. In one case, despite past incidents of falls, the person was alone in her room, with no access to a call bell due to the position of her chair in relation to the length of the call bell lead. Nutritional risk assessments were recorded where necessary, with some associated care planning. In one case the plan directed staff to weigh the person each week, as she was losing weight. These weights had not been carried out weekly, and despite those that had been recorded showing a continued weight loss there was no mention of this in the associated care plan reviews. A food intake monitoring chart in her room had not been maintained for a few weeks, and it was not clear whether this was still being monitored. However, a Doctor had recently been consulted about the weight loss concerns. In another case the person was continuing to lose weight, and the Doctor had suggested dietary supplements; however there was no recorded plan of care that reflected the Doctor’s interventions and suggested treatments. Some weight records fluctuated so erratically it raised concerns about the accuracy of the weighing scales in use. Staff were unable to confirm that the scales had been calibrated recently, if ever. In at least two cases daily records indicated the person experienced episodes of incontinence; in either case there was no plan of care to address this, so it was not clear what care or interventions were required at all. Care plans to address urinary catheter needs were minimal, and provided no guidance at all. In one case that featured as part of the complaint, the plan had been re-written, and to a degree was an improvement on the previous one. However, given that this complaint had identified that the person had been allowed to go into urinary retention without it being recognised in a timely way by the staff, the care plan still made no reference to monitoring the fluid output, and neither did it incorporate any kind of agreed protocol to involve the Community Nursing service when necessary. There was no fluid output monitoring chart in this person’s room, and there was no significant reference in daily records to the output either. In a second case that featured as part of the complaint, the fact that this person had sustained some bruising, and went on to require wound management by the Community Nursing Team, was not recorded in sufficient detail, nor was there a care plan to address these circumstances. There was no reference anywhere to this lady sustaining a bruise type injury either, although accident records showed that she had suffered a fall a few days previously, which may or may not have been a factor. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 15 In a third case that featured as part of the complaint, there were certain factors that were not borne out in relation to the person’s mental condition, however there were some significant mental health issues, which had not been identified on assessment, and had not been care planned for in order to address. Residents themselves spoke quite well of the staff and the care they received, indicating that they were looked after satisfactorily; one said that ‘on the whole staff were very good and helpful’, whilst a small group sitting together said that the staff ‘are kind to us’. However, some did say that some staff were better than others in this regard. Each of the residents’ relatives who completed the CSCI survey responded positively regarding the care and attention their relative was receiving. Residents are able to look after their own medications if they wish and are able to; a number of residents were doing so, and care plans showed that a risk assessment process had supported this decision. Medications were safely stored in both areas of the home, i.e. the nursing and residential side as they are known. The trolley in the residential part of the home, although serviceable and clean inside, was old and well worn, with the metal paint peeling and chipping off. Liquid and external preparations were dated on opening to ensure they were not used beyond their expiry date. Boxed tablets were also dated on opening, and it was possible to carry out five separate medication audits. Two were conducted on the nursing side, one of which was exact, whilst the other revealed a slight discrepancy, with one tablet in excess of that which should have been remaining. Of the three conducted on the residential side, only one was accurate. One of the other two had a discrepancy of one tablet in excess of what there should have been, and more seriously with the other, a discrepancy of ten tablets, which indicated that a whole sachet of painkillers was unaccounted for. None of these situations could be explained at the time, and this must now be investigated with all staff who have access and responsibility for the management of medications. Medication administration charts were clearly printed by the supplying pharmacist, and in the main staff satisfactorily maintain these. Administration charts for the application of external preparations were kept in residents’ rooms where relevant, and in most cases their use linked directly to an associated plan of care, although isolated gaps were found with this. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 16 One diabetic resident, who was receiving personal care only, was receiving her insulin injections from the qualified nurses in the home, with staff working in the residential section of the home signing the chart for having administered it. This must not continue, and it was agreed during this visit that the qualified nurse responsible for administering the insulin must sign the medication chart. The manager has been conducting a weekly audit of medication procedures in both parts of the home, but clearly this has proven to be insufficiently robust, with the concerns identified at this visit. Residents were being cared for in the privacy of their own rooms, and in the main staff were witnessed being kind and respectful towards them. However one incident was overheard when a carer appeared abrupt and irritated with a resident who was ringing their call bell. A few residents confirmed that staff always knocked at their door before entering, and this was witnessed in practice as well. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in this home have opportunities to remain as socially active as they are able and choose, and also have a nutritious diet that offers choice and variety. EVIDENCE: The Grange offers opportunities for social activity, and keeps residents and families informed of activity and events through a notice board and monthly newsletter. Examples of organised activity include visiting entertainers, games afternoons, and gentle exercise classes, watching movies and knitting craft. Different denominational services for religious observance are held, and more recently the home is introducing Quaker meetings, as a need for this had arisen within the resident group. The home also caters for celebrating religious festivals and special calendar dates, including people’s birthdays. A garden fete is planned for the near future. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 18 Residents have been consulted about their personal ideas and preferences for social activity, and a number of ideas came forward at the last consultation for trips and outings. So far some of the requests have not been accommodated, but the recent poor summer weather has not helped in this regard; one trip to the seaside has taken place however. Some residents spoke very happily about the social opportunities available to them; at least two enthused about the ‘fun quiz afternoons’. Some other residents said that they preferred not to participate in planned activity, preferring to spend time resting or watching their television; this choice was fully respected. One resident whose past interest had been embroidery, said that she was unable to pursue this now, but had some of her previous work displayed in her room. Although some of the ladies were enjoying their little social groups and were enjoying knitting, many residents were sitting quietly unoccupied in wheelchairs, and largely unattended for spells during the afternoon. The Grange has no restrictions on visitors to the home, and residents are able to maintain their social and family contacts in accordance with their wishes. Visitors were observed coming and going freely. The home has the advantage of the administrative assistant manager being placed most of the time at the reception desk in the entrance hall. This provides a most friendly and welcoming environment for visitors. Many of the residents said that their families visited them a lot, and many had family photographs adorning their walls and furniture. Each of the visitors who completed CSCI surveys confirmed that they felt that staff in the home kept them in touch and well informed as needed. Visitors may also stay for refreshment with their relative if they wish. In the main the residents here are able to choose how they spend their time, although many are much more reliant on the staff to assist them in pursuing any kind of choice. One more independent person said that she could do as she pleased, and ‘come and go as she liked’. Another appreciated being able to use different areas of the home, particularly the attractive courtyard garden when she wished. Many of the residents’ private bedrooms contained a variety of personal belongings and treasures, making rooms appear more homely and individual in accordance with the occupant’s choice. The home’s information brochure contains some good points of contact for residents and their families who might be interested, for local and national guidance, support and information agencies for people using care services. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 19 Residents also have a good degree of choice with their meals. They are asked each day about their selections from the menu, and different choices, tastes and dietary needs were catered for during the mealtimes that were observed. The meals looked wholesome, nutritious and plentiful, and residents all spoke very positively about them. One lady said that the food was ‘lovely’, and that she really appreciated staff taking the trouble to ‘warm her milk for cereal just as she liked’. This person also confirmed that her special dietary requirements were properly catered for. Staff were in attendance in each of the rooms where meals were served, and were providing help as needed. Music or television was playing loudly in most areas during the mealtime, which may not have been to everyone’s taste when eating their meal. The service in Nightingale lounge was particularly intrusive to some residents. A number of plated, covered meals were placed on the dining table where two people were already eating their meal, whilst being checked and sorted and matched up with cutlery before taking round to different locations. This caused some disturbance on the table given the distraction the sound and activity caused, with the carer leaning across the table several times to pick up pieces of cutlery. The kitchen was seen after the lunchtime service, and appeared organised. Appropriate catering records were maintained, except for a record of deepfreeze temperature monitoring, as would be good practice. The cook was well informed about residents’ needs, preferences and choices, including some of their preferred portion sizes. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People living in this home do not all feel assured by the home’s procedures to address their concerns, and are not fully protected against abusive practice due to the management’s failure to adhere to the Adult Protection policies. EVIDENCE: The home has a clearly written and accessible procedure for dealing with any complaints and concerns that may be received. A complaints log is maintained, and records for three complaints more recently received were inspected. These demonstrated that the issues had been addressed and responded to. However, although some residents confirmed that they knew how to raise concerns, some said that they would be reluctant to do so. One person said ‘you don’t dare raise complaints here’, and ‘you have to be careful what you say’. A second said that he would raise concerns with two named senior carers in the residential side of the home, and he was not sure if he knew the manager. Another said that she would be entirely happy to raise concerns with the administrative assistant manager, and that she never saw the manager to do so anyway. Another person said she would raise her concerns with the The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 21 manager, but she didn’t know who she was, and as far as she was aware did not see her anyway. A complaint was received by CSCI just prior to this inspection, the detail of which features throughout this report. The concerns were eventually brought to the attention of CSCI, as the complainant had become increasingly frustrated at the manager’s alleged failure to listen to them and respond appropriately. The Grange has policies and procedures that are designed to promote the safety and wellbeing of vulnerable residents, and protect them from any abusive practices. Staff have received the necessary training in this regard also. The manager has undergone training in relation to the recently introduced Mental Capacity Act, and it is the intention of the Care Provider to cascade this training to all staff, and is currently exploring the best ways of doing this. Staff confirmed that they had undergone training in prevention of abuse, and staff disciplinary records clearly demonstrated that the Whistleblowing procedures work well in practice. However, despite disciplinary proceedings being instigated with two members of the care team for separate incidents constituting abusive practice, the appropriate actions had not been carried out as a consequence in the interests of protecting residents. In the first case a condition of the worker’s reinstatement was that they were subjected to weekly meetings with the manager for supervision and monitoring purposes; this had not been followed through, with weekly meetings apparently not taking place. In the second case the disciplinary investigation had ultimately resulted in the worker being dismissed for abusive practices towards residents. The home had not referred this worker to the POVA (Protection of Vulnerable Adults) register, as was required by legislation. This must now be done retrospectively, and it was agreed that the manager would now carry this out. In addition to this, the manager has failed to provide CSCI with the necessary notification of abusive practices against residents, and of the ensuing staff disciplinary proceedings as was required under the Care Home Regulations. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in this home are provided with a reasonably comfortable and homely environment, but slow progress to improve and repair certain aspects of it is now having a detrimental effect on parts of its appearance, safety and hygiene. EVIDENCE: On the whole this home has generally been maintained, although it continues to show extreme signs of wear and tear and fatigue in many areas, despite this having been reported on previous occasions. The CTCH Ltd group as a whole employs a maintenance team, but it was reported in the home’s Annual Quality Assurance Assessment (AQAA) for CSCI that responses to maintenance requests have been slow. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 23 Since the last inspection one of the assisted bathrooms has been refurbished as required, and redecoration of bedrooms has been ongoing. The home’s AQAA makes reference to plans to install new assisted bathing and showering facilities to each floor. Walking around the building there are many areas that are very pleasant, comfortable and homely for the residents, but there were a number of problems noted in the general upkeep of the premises. A number of light bulbs were not working, numerous patches of wallpaper were torn or lifting, and woodwork around doors and skirting boards were very damaged. Corridor lighting was quite dim in places. A drawer front in a bedroom, identified at the time of the inspection, was completely broken. In another room, identified at the time of the inspection, the toilet base was broken, and also in this room there was a filthy, stained towel left on the bath. A bath hoist remains in situ in the first floor bathroom 4, despite a recommendation to remove it last time, as it is not serviceable. This bath was being used to store items, and was not in use as a bathing facility; however the condition of it was dirty, with a heavy build up of dirt and debris around the plughole. The clinical waste bin in this bathroom did not have a lid on it and faecally stained continence aids were exposed. The Osprey lounge is currently not accessible to residents as it is being used for storage. The carpet in Swallow lounge was heavily stained, with a more thorough cleaning technique necessary. Throughout the home there were several liquid soap dispensers missing as they were reported to have broken; bars of soap had been substituted, and assurances were received that this was only temporary, with new dispensers being provided. A metal stand for use with a urinary catheter bag was in a poor state of repair, with excessive rust on it, rendering it unhygienic. There was a boiling hot kettle of water in Sandpiper lounge, at a level likely to cause harm to residents, and a request was made to remove this immediately. Many of the beds in residents’ bedrooms were neat but not made until later in the day; some of the blankets seen were thin and appeared old and worn. The carpet on one of the staircases, the condition of which has been a concern for a while, is currently being replaced. One of the visitors commented on survey how ‘disgusting the carpet was’ and ‘how it let the home down’. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 24 It transpired that this person had been forced to use these stairs during a lift failure. The manager failed to inform CSCI, as is required, of this lift breakdown at the time. There is a regular laundry service here, but it is extremely busy, and it is proving difficult for the laundry assistant to maintain a satisfactory service for the residents due to the huge volume of laundry going through it, which has recently been compounded by machine failures, which have not received very prompt maintenance attention. One of the resident’s relatives commented that often laundry goes missing, and that the laundry service is poor. One particular resident said that she has to ‘keep a good eye on her laundry, as stuff often goes missing’ or is ‘incorrectly delivered’ to her. Another person said that the home ‘needs more laundry assistants’. There was a rail of clothing in the laundry room, which was causing some concern for the laundry assistant, as the items were unnamed, making it difficult or impossible to know who to deliver items back to. Residents or their relatives are asked to check these things and to name items clearly. One of the tumble driers that were out of action during this visit had apparently caught fire some weeks ago, which fortunately had been successfully extinguished by staff, and for which the Fire Brigade had attended. The manager has failed to notify CSCI of this event, as she was required to do. A new machine was being purchased to replace it. The home was generally clean and odour free. One strong odour was evident in one of the resident’s bedrooms, and this was discussed with the deputy manager, as the concern was that this was being caused by a particular health condition that may have gone unchecked, due to the person’s independence. Wheelchairs were cleaner on this occasion, although at least one was seen that was filthy and unhygienic. The Group Care Manager has recognised that this is an area for continued attention from the staff, and has already advised them so. CSCI has been liaising with the Group Care Manager regarding the home’s management of clinical waste, and has given advice in this regard. The home has a contract for the correct collection and disposal of clinical waste, but this does not include the removal of Grade E waste (incontinence material). This waste is bagged and goes into the household waste, which reportedly goes to an appropriate landfill site. However, it is important that the home risk assess this waste for anything that may be infected, as this would require an alternative method of disposal. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in this home receive care from a generally competent workforce, although failure to consistently provide all the necessary safeguards in relation to their recruitment and induction to the home is posing a degree of risk to residents. EVIDENCE: Residents in the home spoke well of staff at The Grange, saying things like ‘they are very helpful’, ‘kind’, and ‘they come quickly if I ring my bell’. One relative said that the staff were ‘kind and thoughtful’, but that the home ‘needed more’. Staffing rotas are maintained, and these show a good number of staff at various times of the day to meet the needs of the large number of residents and the widespread layout of the home. The staff group is divided into two teams, one to work with nursing residents and one to work with residential residents. The home manager works supernumerary to these numbers, and retains overall responsibility for the whole home, including nursing and residential residents and staff. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 26 The aim is to have sixteen staff on duty during the morning, which is usually made up of two nurses and fourteen carers. During the afternoon/evening and night the aim is to have one nurse and ten carers, and one nurse and four carers respectively. There is some agency use at present until full numbers can be achieved again through ongoing recruitment. There is an ancillary team to support the nursing team, which is made up of cleaning, catering, laundry, maintenance and administrative staff. The home is making good progress with the National Vocational Qualification (NVQ) training programme for care staff. There are eighteen care staff qualified to at least level 2 at this time, with a further nine already working towards the award. Personnel files relating to five members of staff who had been recruited in recent months were inspected. In each instance, the prospective employee had completed an application form providing details of their employment history. Two written references had been provided in four cases, with only one in the fifth case, which does not meet with the requirement for two, issued at the last inspection. The Personal Identification Number confirming eligibility to practice for a qualified nurse had not been checked out with the Nursing and Midwifery Council as is required. Medical information to confirm fitness for the work had been obtained, and it was noted that sensitive detail was left open on personnel files; it was recommended that such information be held in a sealed envelope. Correct POVA (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) screening had been completed for each person. The General Social Care Council Code of Conduct for care workers had been issued to each member of the care staff. New staff are inducted to the home, although records show that this is not necessarily carried out in the timeliest of ways. When staff commence employment they are assessed in relation to their existing skills, knowledge and experience, and an induction programme is then decided upon to suit the needs of the individual. This could mean that some go to an external care training provider for more in depth training, although as previously reported this has not always been done quickly enough in some cases, or they could just have an in-house induction, which is not directly related to care issues and is more about the home itself, and health and safety issues. New staff work under supervision, and some workers’ records showed the names of their mentor. Training records demonstrated that staff have access to a good range of training opportunities in topics relevant to their role and responsibilities. Each is encouraged to maintain a professional portfolio. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 27 As part of the inspection to look into the complaint previously reported, it was necessary to explore in more depth the quality and frequency of manual handling training that is delivered to staff. The home has a designated manual handling trainer on the staff team, who was equipped to deliver this training five years ago; it was not accurately established when this person’s knowledge and skill was last updated, five years being one possibility mentioned. The policy is that staff undergo at least a 3 hour training session, involving theoretical and practical knowledge when they commence employment, but in the absence of timely induction training as reported above, this does not always happen at the most appropriate time. The trainer indicated that she did not always get the necessary amount of time to fulfil this duty properly. This has resulted in some new staff becoming involved in manual handling procedures with residents, albeit under supervision, before having had the appropriate training. Following any initial manual handling training, updated training is provided thereafter on an annual basis, which involves practical training and assessment of each worker. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 28 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The health and safety of people living in this home is being compromised through shortfalls in the management practices here, which have not been based on openness and respect. EVIDENCE: The registered manager for The Grange was not present during this unannounced inspection due to planned leave, and the outcomes of this visit were shared in full with the Group Care Manager, the deputy manager, and the administrative assistant manager. A number of concerns were identified during this visit, which has been reported throughout this inspection report, and which link directly to significant failures The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 29 in the management of this home. There are a number of instances where information has not been shared as appropriate or required with the relevant authorities. A small number of residents have placed personal money with the home for safekeeping. Monies were held individually and securely. Clear and transparent records for each person, which included transaction details, running totals, and receipts were kept. Two random audits on residents’ monies proved to be correct. A witness had countersigned any staff signature, when acting on a resident’s behalf. Residents have had a degree of opportunity to have a say in how their home is run. In the absence of regular resident meetings, this has been with the use of survey forms, of which there have been two this year. The first focussed on the provision of social activities, and the most recent focussed on the food; not all residents participated in this. Results were collated and action plans were drawn up to address issues of concern on the first survey results, whilst the latest one had yet to be collated and drafted. These surveys appear restrictive, and more comprehensive surveys would give residents a better chance of having a voice regarding all aspects of their home and their care. In view of the significant failures in this home on this occasion, it is now required that the Care Provider monitoring visits that are required in the Care Home Regulations every month, be carried out meticulously, with a clear emphasis on quality monitoring and improvement; monthly reports must be submitted to CSCI. Staff have received Fire Safety training, which encompassed the home’s procedures, and some practice fire drills. Due to prior knowledge of the inadequacy of the home’s Fire Risk Assessment, CSCI contacted the Fire Safety officer ahead of this visit, in order that he could inspect it for himself. The outcome of the Fire Officer visit was unclear during this CSCI inspection, as after it had taken place the manager had apparently reported to the administration assistant manager that everything had been fine, and that there were no evacuation procedures to follow in the event of a fire, with residents having to be left in their rooms. This would not fit with what is expected under the Fire Safety Order, as at least a phased evacuation would be expected under such circumstances, and the Fire Officer’s report is now awaited. Staff have received training in First Aid, and there are now ten staff with a First Aid qualification. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 30 Accident records are maintained, and although there was not one for last month, monthly audits are carried out. However, given the incidence of falls reported in standards 7 and 8 above for which there was no record of corrective action being taken, it is doubtful that audits are robust or meaningful at all. One of the nursing team fell on the stairs last month, and she said that this had been due to the condition of the carpet on it (it was reported to have been torn; this was the carpet now being replaced, as reported above). Despite this staff member having to go on sick leave because of her sustaining an injury for a period in excess of three days, the manager made no referral under RIDDOR, as was required, neither was a notification sent to CSCI. It was noted that workmen’s ladders were left in precarious positions around stairwells whilst they were absent from the area. It was reported that staff have raised this with safety in mind, and were told that there was nowhere else to put them. There are servicing arrangements for the lift, for gas appliances and boilers, and electrical equipment. The hoisting equipment had not been serviced or checked for safety for a year, although it was reported that this was planned to take place every six months; an explanation was not forthcoming as to why this had not been followed up. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 31 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 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 32 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 OP3 Regulation 14(1a) Requirement Timescale for action 31/10/07 2 OP7 OP8 15(1) 3 OP8 13(4c) 12(1a) 4 OP7 OP8 13(4c) Assessments carried out preadmission or in the home, must be completed and recorded in full, and cover all aspects of the person’s needs, including mental health. Care plans must be devised and 30/11/07 written, which clearly show how residents’ needs are to be met in respect of their health and welfare. Pressure sore risk assessments 31/10/07 must be reviewed and amended appropriately in order that vulnerable people using this service can receive the appropriate level of care to reduce the risk of them developing a pressure sore. An assessment of risk in relation 31/10/07 to falls must be carried out and recorded in residents’ care records, with the appropriate care planned and action taken to reduce or eliminate, as far as practicable, the level of risks identified. (This requirement is repeated from the last inspection) DS0000016608.V344911.R01.S.doc Version 5.2 The Grange Page 33 5 OP8 12(1a) 6 OP8 12(1b) 7 OP8 17(1a) Schedule 3(j). 13(6) 8 OP7 OP8 15(1) 9 OP9 13(2) People using this service who are nutritionally at risk must have their weight monitored, in order that appropriate actions can be taken to meet their health needs when weight loss is identified. In cases where there is risk to health in relation to the management and potency of a catheter, staff must monitor the fluid output so as to promote early recognition of a problem and take the necessary action to ensure that the health needs of the resident are met. Detailed records must be made in residents’ care records regarding any changes to their condition, or of any incident that is detrimental to their health and welfare including any injuries or bruises. This must include the nature of it and whether medical treatment was required. Fully detailed care plans must be devised and recorded, which will address the needs of residents and provide guidance for staff in relation to the management of wounds, mental health issues and the care of a catheter, where these issues are of relevance specifically. (This requirement is made with specific reference to the elements of the complaint) A full audit and investigation must be carried out regarding the medication stocks and the manner in which they have been administered by staff, in an effort to establish a reason for the stock discrepancy identified. The results of this audit must be submitted to CSCI. 31/10/07 31/10/07 31/10/07 31/10/07 30/11/07 The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 34 10 OP16 22(3) 11 OP18 13(6) 12 OP18 37(g) 13 OP19 23(2b) 14 OP19 23(2d) 15 OP19 37 The registered manager must ensure that all complaints and concerns received are fully investigated, in order to protect the interests of people using the service. The registered manager must ensure that disciplinary actions taken with staff are carried out rigorously through supervision, and that, where appropriate, referrals to POVA are carried out in order to protect the vulnerable people using the service. The registered manager must ensure that when disciplinary procedures are instigated for staff in alleged incidents of abusive practice, CSCI is informed through a formal notification without delay. The registered person must ensure that the necessary steps are taken to repair the broken drawer, toilet base and light bulbs reported under this standard. The registered person must notify CSCI of their plans to attend to the refurbishment of areas affected by poor maintenance and decoration in the home. The registered manager must ensure that CSCI is informed without delay, through a formal notification, when there is an event which adversely affects the well being of people using the service; specifically a lift failure and an outbreak of fire on this occasion. 31/10/07 31/10/07 31/10/07 30/11/07 30/11/07 31/10/07 The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 35 16 OP26 13(3) 16(2k) 17 OP26 13(3) 16(2j) 18 OP26 16(2j) 19 OP29 19(1) Schedule 2(3) 20 OP29 19, Schedule 2(5) 21 OP30 13(5) 18(1.ci) The registered manager must ensure that an enclosed clinical waste disposal bin is provided in the identified bathroom, so that such disposables are not left exposed to cause an infection control risk to vulnerable people using the service. The registered manager must ensure that the identified catheter bag stand is replaced with a hygienic alternative, so as not to pose an infection control risk to vulnerable people using the service. The registered manager must ensure that residents’ wheelchairs and bath hoists are maintained in a clean and hygienic condition. (This requirement is repeated from the last inspection) The registered manager must ensure that two satisfactory written references are obtained when employing prospective staff, prior to them commencing work. (This requirement is repeated from the last inspection) The registered manager must ensure that the Personal Identification Number (PIN) of qualified nurses is checked for eligibility with the registering authority (The Nursing and Midwifery Council) before they commence employment in the home. Staff must receive manual handling training as part of their structured induction training at the commencement of their employment. 31/10/07 31/10/07 31/10/07 31/10/07 31/10/07 31/10/07 The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 36 22 OP33 26(5a) 23 OP38 37 24 OP38 13(4c) The registered provider must 31/10/07 compile written reports required under this regulation and provide such reports to CSCI every month, as part of the quality monitoring process for this service. The registered manager must 31/10/07 ensure that CSCI is informed without delay, through a formal notification, of accidents involving staff. The registered manager must 31/10/07 ensure that robust auditing of accidents is regularly carried out, with all necessary actions taken as a consequence to reduce any risks identified to the people using the service. 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 OP8 OP15 OP19 OP33 Good Practice Recommendations The weighing scales in use for residents should be calibrated for accuracy. Deep freezer temperatures should be monitored and recorded in the kitchen. An audit should be carried out on the bed linen, specifically blankets, so that a replacement programme can be instigated where needed. More comprehensive surveys/questionnaires should be devised as part of monitoring quality and levels of satisfaction with the residents. The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 The Grange DS0000016608.V344911.R01.S.doc Version 5.2 Page 38 - 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. 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