Inspection on 15/08/05 for The Grange

This inspection was carried out on 15th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Grange 01/02/06

The Grange 05/10/04

The Grange 03/06/04

The Grange 03/07/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Grange 88 Southgate Eckington Sheffield S31 9FT Lead Inspector Marie Bonynge Unannounced 15 August 2005 2.00pm 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 C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Grange Address 88 Southgate Eckington Sheffield South Yorkshire S31 9FT 01246 348644 01246 348601 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) Derbyshire County Council Leshia Kathleen Bunt PC Care Home Only 25 Category(ies) of 25 Places - OP Old Age registration, with number of places The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None stated Date of last inspection 5th October 2004 Brief Description of the Service: The Grange is a purpose built care home registered to provide personal care and accommodation for up to 25 older people. The home is located in the village of Eckington close to a number of shops including a supermarket, chemist and post office. There are three lounge / dining areas, one on each wing of the home. A kitchenette is adjacent to each lounge for the provision of drinks and snacks. The home is served by a central kitchen and laundry. There are 25 bedrooms offering single accommodation with en suite facilities including a shower. A conservatory provides additional seating and dining space. The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in August 2005. It found that most of the national minimum standards were met or partially met and many of the requirements made at the last inspection had been complied with or work had progressed to meet these. Some of the inspection methods used included discussions with residents, staff and the deputy relief manager. A tour of the building was made and records were examined including care plans, health related records, medicines charts and staffing rotas. The Inspector was given a warm welcome by residents and staff and cooperation was provided throughout this visit. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 6 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 C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 7 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 A thorough needs assessment contributes to the home being able to provide a comfortable and homely environment that meets with the expectations of residents. EVIDENCE: Comprehensive assessment information had been obtained for the three residents whose care plans were examined. The home had also completed a detailed needs assessment that included a history of falls and important family and community contacts. A plan of care was in place for these three residents and the Inspector was advised that personal service plans were in place for all of the residents accommodated. A significant amount of progress had been made in respect of the daily living plans and detailed information was recorded about the likes and dislikes of the person and the way in which they preferred their care to be carried out. Two of the residents spoken to on this visit were aware of their care plans and said that they had been involved in their development. A requirement made at the last inspection has therefore been complied with. The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 8 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, 9 and 10 Care planning was generally clear and comprehensive with residents’ health care needs generally being met. However some gaps in the recording of nutritional assessments and weight could pose a potential risk to residents. EVIDENCE: The daily records of three residents were examined. These indicated that details were now being recorded as to how the residents’ needs in respect of their health and welfare had been met on a daily basis. A requirement made at the last inspection has therefore been met. Progress has continued to be made in respect of the development of care plans in general and staff were aware of the needs of residents and how the care plan should be implemented. Discussions with residents indicated that they were satisfied with the level of care being provided with one resident commenting that they ‘couldn’t ask for better’. A nutritional assessment had been completed for all of the residents whose records were examined, however this had not been reviewed consistently for two residents and was not consistent with the care plan where a change in need had been identified. Records indicated that the health care needs of residents were generally being met and there was good access to dental services, chiropody and nursing services. The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 9 Medication records were examined in respect of three residents. These indicated that improvements had been made with regard to the medication systems in place. 6 requirements had been complied with from previous inspection reports. Discussions with staff and the examination of records indicated that staff had attended medication training. The maximum and minimum temperatures of the medication refrigerator were being recorded, however these were outside the recommended range and no action had been taken to resolve this. Discussions with 5 residents indicated that they felt their privacy and dignity was maintained at all times, this included staff knocking on bedroom and bathroom doors before entering. One resident commented that they felt they had choice about all aspects of their daily life and care and that staff were approachable and respectful. The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 10 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, 14 and 15 Activities and meals are provided that generally suit the expressed preferences of residents. This assists in contributing to a pleasant atmosphere and the overall high level of satisfaction for residents. EVIDENCE: Three residents who were interviewed reported that they felt the home provided sufficient activities and catered for their interests. These included going to the shops, religious services and bingo and cards. Reminiscence groups had continued to be developed for residents with dementia. Residents’ interests were recorded and acted upon. A sample of menus had been provided to the CSCI and the daily menu was seen in each of the lounges. This indicated that residents had three meals each day, the main cooked meal being at lunch-time. Positive comments were made about the meals provided and it was said that the food was plentiful. The tea-time meal provided on this visit was appealing and a choice was available. The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 11 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 homes complaints procedure was clear and accessible and served to ensure that complaints would be dealt with appropriately and in a timely manner. EVIDENCE: A comprehensive complaints procedure was in place and was displayed at prominent points around the home. Minor complaints were being recorded and a record was kept of the action taken and the outcome. No complaints had been received by the CSCI or the home since the last inspection. Residents reported that they could speak to a member of staff if they were concerned about any aspect of their care. The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 12 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, 20, 25 and 26 The standard of the environment within the home is good and provides residents with an attractive and homely place to live. EVIDENCE: The Grange is located in the village of Eckington, close to shops and other amenities and is suitable for its stated purpose. There is a regular programme of routine maintenance and renewal of the building and this is evident in the high standard of accommodation provided internally and externally. The home was generally well furnished and comfortable and homely. Discussions with residents evidenced that they were pleased with their home and felt that the standard of accommodation met with their expectations. The home was warm and well ventilated on this visit and residents reported that the temperature was comfortable for them. One resident commented that the lounges and other communal space were always kept clean. The grounds were well kept and attractive. Arrangements had been made for access to be provided for all residents to the garden although this was not completed yet. The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 13 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) 27 and 29 The home was staffed in accordance with the recommended guidance to meet with the assessed needs of those residents accommodated on this visit. Recruitment processes were in place that contributed to safeguarding the interests of residents. EVIDENCE: A sampled of staffing rotas was examined for the months of July 2005 and August 2005. These indicated that the home was staffed according to the numbers and dependencies of residents accommodated. A system was in place to cover for any periods of sickness or holidays. Residents interviewed said that if they needed anything a member of staff would always come. Staff were directly observed to be attentive towards residents. Information provided on the pre inspection questionnaire and from discussions with staff indicated that thorough recruitment systems were in place. The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 14 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) 33, 36 and 37 The home regularly reviews aspects of its performance via an established system of self review and consultation that includes monthly visits from the provider. EVIDENCE: An established system of quality assurance continues to be implemented and developed both internally and externally via Age Concern. Residents’ views were sought and staff were clear about the aims and objectives of the home. The policies and procedures manual had not yet been updated, however arrangements had been made for these to be reviewed and implemented. Regulation 26 Provider visits were taking place and residents reported that their views about the home and their care were regularly sought via reviews and questionnaires. Staff commented that regular supervision took place and a completed supervision plan was seen in the office. Records were generally well kept and securely stored. The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 15 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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 3 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 x 2 x x 3 3 x The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 16 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 OP7 and OP8 Regulation 15 (1) (2) (b) (c) Requirement Timescale for action 31.12.05 2. OP9 3. OP19 4. OP33 The registered person must ensure that monitoring of residents nutrition and weight is consistent and recorded in accordance with the care plan. 13 (2) 23 The thermometer for the (2) (i) medication refrigerator must be reset after the daily recordings of maximum and minimum temperatures have been made. Staff must know what action to take if the readings do not lie between 2 degrees Celsius and 8 degrees Celsius. 23 (1) (a) The premises must be suitable (2) (a) for the purpose of achieving the aims and objectives set out in the statement of purpose including providing access to all parts of the home used by service users inside and out. 10 (1) 12 Policies, procedures and (1) (a) (b) practices must be regularly reviewed in light of changing legislation and of good practice advice from the Department of Health, local / health authorities and specialist / professional organisations. Original timescale 01.12.04. New timescale 31.12.05 Previous timescale 01.02.05. New timescale 01.02.06 Origianl timescale 01.02.05. New timescale 01.02.06 The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 17 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Grange C52-C02 S35808 The Grange V244363 150805 Stage 4.doc Version 1.40 Page 19 - 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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