Inspection on 04/03/09 for The Grange

This inspection was carried out on 4th March 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Grange 07/02/08

The Grange 10/09/07

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 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Grange Grange Road Northway Tewkesbury Glos GL20 8HQ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ruth Wilcox     Date: 0 5 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 42 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 42 Information about the care home Name of care home: Address: The Grange Grange Road Northway Tewkesbury Glos GL20 8HQ 01684850111 01684290221 alison@ctch.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): CTCH Ltd Name of registered manager (if applicable) Mrs Samantha Jane Williams Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 69 The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home 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. It is owned and managed by the C.T.C.H Ltd group of homes, and 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 smallCare Homes for Older People Page 4 of 42 care home 69 Over 65 69 0 Brief description of the care home 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 465 pounds to 675 pounds, depending on the level of residential or nursing need. The home also provides care at the local authority contract rates. Optical services, chiropody, hairdressing, newspapers, and toiletries are charged at individual extra costs. Care Homes for Older People Page 5 of 42 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last Key Inspection for this service was on the 7th February 2008. 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. One Regulatory Inspector and a Pharmacist Inspector carried out this inspection on two full days in March 2009. Care records were inspected with the care of seven residents being closely looked at in particular. The arrangements to manage residents medications were inspected. Care Homes for Older People Page 6 of 42 We spoke to a number of residents and visitors 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 number of residents, staff and visiting health care professionals to complete and return to CSCI if they wished. Some of their comments feature in this report. 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 arrangements for the recruitment, provision, training and supervision 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. We required an Annual Quality Assurance Assessment (AQAA) from the home, which was provided, the contents of which informed part of this inspection. What the care home does well: What has improved since the last inspection? Staff were working towards broadening the social activity for residents, whilst remaining mindful of individual choice and disability, with a variety of group and individual opportunities for engagement. The number of complaints received had greatly reduced. Some very good arrangements were now in place to audit, action and effect improvements on the basis of any that were received. People were now feeling very reassured by this. The home has now employed its own maintenance person to work solely at The Grange. Although there is some improvement in this area on this occasion, there is still a lot of work left to do to improve the environment further. Care Homes for Older People Page 8 of 42 There is greater stability in the home now, with a committed and hard working manager and core team of staff, and with an emphasis on improving staff cohesiveness. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 42 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 42 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Access to information about the home and a pre-admission assessment prior to coming in here gives prospective residents an assurance that their needs can be met. Evidence: The homes AQAA confirmed that a copy of the homes information brochure was issued to all prospective residents. It confirmed that interested parties were welcome to visit and view the home at any time and that prospective residents can stay to meet other residents and have lunch. One resident said that they had come here on recommendation, and that they were happy with all aspects of the home and the staff. Another said that this was where they wanted to be after they had visited it with their family. A large information brochure was available to read, which included the homes Care Homes for Older People Page 11 of 42 Evidence: Statement of Purpose and Philosophy of Care. The Statement of Purpose had been updated to accurately reflect the new management details and clinical lead. All residents were admitted to the home on the basis of a full pre-admission assessment that was undertaken by two members of staff, including a nurse if appropriate. Information, assessments and care plans were also sought from other health and social care professionals involved in the case. The AQAA told us that letters confirming a placement at the home following the assessment were issued in all cases, and we saw examples of this within records. We spoke to some families who confirmed they had come to view the home unannounced before making a decision about it. They said they were made most welcome, were shown around and had any questions answered. Each confirmed they were given an information brochure. They also confirmed that their relative had received an assessment by someone from the home prior to their admission. The Grange does not provide intermediate care. Care Homes for Older People Page 12 of 42 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home can expect to have their health and care needs met, however some shortfalls in documented plans of care and weaknesses with the management of medications are posing a degree of risk in this regard. Evidence: Each resident had an individualised plan of care in place that had been drafted on the outcome of a full assessment, and which had been done in consultation with them. We selected seven care plans to inspect more closely on the basis of needs, sometimes complex, and on the basis of information shared with us by the home prior to this inspection. Care plans covered residents needs in areas applicable to them, and in many cases gave good guidance to staff when delivering care. Some aspects were particularly person-centred, although this approach needed to be more consistent, with all staff adopting the same approach to care planning. Care Homes for Older People Page 13 of 42 Evidence: There were some discrepancies between what was recorded and the care actually being delivered. Care plans for one particular resident directed staff to help the person with their hearing aids. Also the manual handling risk assessment said that the person needed two carers to help them walk. However when we met this person they told us that they had never worn hearing aids and that they only ever needed one person to help them to walk. This was also borne out by staff in practice. In another case the Community Psychiatric Team were involved in the care and treatment of the individual, but there was little recorded about their interventions in the care plan, or the likely triggers in the persons condition and behaviour for calling them. Care plans contained a variety of risk assessments to take account of peoples mobility and falls, vulnerability to developing pressure sores, and nutritional needs. We saw examples of risk assessments for the introduction of bed rails, although recording on these was not comprehensive, with signed consent obtained from the individual as part of this. A number of those for whom bed rails had been assessed as necessary, or had been requested, were not provided with soft pads on the bed rails as a form of protection. We saw two examples of where a high risk of the person developing pressure sores had been identifed. Although appropriate support equipment and care was in place the plans contained no actual guidance regarding preventative actions and monitoring arrangements necessary to help prevent sores developing. In another case the plan of care directed staff to set a gastrostomy feed at the rate directed by the dietician. We could find no record of what this rate was. The plans had been regularly reviewed. However some of this was of little value given that reviews contained sparse information and had not triggered a change in the actual plan of care when the persons circumstances and condition had changed. Multi disciplinary health support was accessed to meet residents needs, and we saw and heard about examples of residents health and well-being improving as a consequence. Staff had worked extensively with the Care Home Support Team (CHST) for the benefit of the residents. In one case the person was reported to have been seen by the diabetic specialist nurse but there was no actual record of this anywhere, and it did not feature in their care plan. Recorded actions such keep BMs (blood sugars) high were not descriptive enough to know what this direction meant. Care Homes for Older People Page 14 of 42 Evidence: One particular relative told us that staff at all levels see to the special needs of the residents and that their relative spoke well of their care and enjoyed the comfort and supervision that the home offered. They also reported a high standard of support from the manager and staff. One resident told us staff always answer when called although their work load is heavy. We spoke to a number of other residents and all spoke very positively about their care. All appeared well dressed and clean. We spoke to three visitors, each of whom was very complimentary regarding their relatives care and the staff and manager. They told us that their relatives quality of life and health had improved since being here. The AQAA told us that individuals cultural preferences were reflected in care planning and that the home respected their beliefs. We met one person whose diverse beliefs regarding home comforts and way of life were challenging to staff, but they were sensitive to these and respected the persons choice. One visiting healthcare professional told us that the home needed to adopt a more integrated approach to the primary health care team, although went on to report that things had improved in the past year. However in their experience the levels of care in the home could be variable. It was also stated that messages regarding medication and care sometimes did not get passed on or acted upon. In contrast, two other professionals told us that their instructions had always been carried out. Pharmacist inspectors report about arrangements for the handling of medicines that were inspected on 5 March 2009. As part of this key inspection, one of our CSCI (The Commission for Social Care Inspection) pharmacist inspectors looked at some of the arrangements for the management of medicines. This included looking at some stocks and storage arrangements for medicines and various records about medication. We saw how staff administered some medicines to people living in the home. The pharmacist spoke to the manager, the clinical lead nurse, two nurses and two residential care leaders, one person living in the home and visited several bedrooms. We gave full feedback after the inspection to the manager and group care manager about the medication issues we found. At the time of the inspection only one person living in this home was assessed as able to look after and administer some medicines themselves. Staff told us that most Care Homes for Older People Page 15 of 42 Evidence: people wanted staff to deal with their medicines but if people requested to look after their medicines themselves there was an assessment process to make sure this would be safe for them. Most people living in the home were therefore totally dependent on the staff for this part of their care. Registered nurses and trained residential care staff administered most medication (except for certain prescribed skin products that carers applied). The residential care staff had undertaken training and assessment about the safe handling of medicines. The carers who were delegated to apply some skin medicines did not seem to have specific training for this task. The evidence from this inspection (poor recording for some skin treatments and lack of names and opening dates on the cream or ointment containers to allow a proper stock rotation system in accordance with good practice) was that some training for this task is needed. During the inspection we saw staff taking the medicine trolleys and records around the home to administer medicines to some people. Staff asked people if they needed medicines for pain. In some cases the 8am medicines were administered at 10.30am and some lunch doses at 2.30pm. Staff told us that the administration of medicines can take a considerable time. The home have already taken action to try and improve on this. We discussed the importance of having the correct times and intervals between medicine doses. This is to make sure that people obtain the best effect from the medicines and that they are not at risk of harm because of receiving doses too close together. This is particularly important for people taking medicines containing paracetamol where there must be a minimum four hour interval between doses. Staff we spoke to were aware of this. The correct interval can be difficult to achieve particularly if medicine administration times are delayed and vary signifcantly from what is printed on the records. Staff did not generally record the time if they were running late. Further action is needed to help protect people in the home from risks of not receiving their medicines at the right times. A number of medicines were prescribed to use as required. For some people in the nursing unit we found there was additional written information in care plans or on protocol forms for some medicines. These provided further guidance to staff responsible for administering medication to help understand what the direction as required meant for this person and medicine. This should help make sure people receive these medicines in a consistent way and to meet identified needs. We pointed out a number of other medicines where this information was still needed or where the protocol already written needed better information so that there would be clearer guidance for staff. This system was not in use at all on the residential unit so action is needed to put this in place. The protocols that were in use needed signing and dating by the person writing them so that it was clear who had written them and how up to date they were. We looked in another care plan for managing care of diabetes and pointed out that more information would be helpful about target blood glucose levels Care Homes for Older People Page 16 of 42 Evidence: and any necessary action specific for each person. Staff we spoke to were able to describe the limits for this person. Another care plan for administering medicines by a feeding tube needed improving by adding the specific information about administering medicines in this way. The prescription for these medicines should include the direction to administer in this way so that the nurses have the authority to use this unlicensed method and the pharmacist is aware of this when they supply the medicines. The pharmacist could advise about other formulations more suitable for administration by tube if they were aware. We spoke to one person who was looking after and responsible for taking some of his or her medicines while staff were responsible for others. The medicines we were shown in the bedroom and what the person told us did not agree with the medicine records, so the arrangements made for this person must be reassessed. Medicine records were in place but these must also include details of what and when medicines are handed over to the person to look after. As this was not done we could not check what medicines staff had given this person this month. Risk assessment forms were completed and a lockable drawer for storage was provided in the bedroom. This person was also prescribed two medicines that must be taken at least two hours apart in order to prevent the action of one tablet being made less effective by the other. This may not have been happening so the arrangements need adjusting to allow this. There were arrangements for keeping records about medication received, administered and leaving the home or disposed of (as no longer needed) for each person in the home. Complete and accurate records about medication are very important in a care home as there are a number of different staff involved with medication and people in the home are dependent on these staff for their medicines. Proper records help make sure that people are not at risk from mistakes, such as receiving their medicines incorrectly, and there is a full account of the medicines the home is responsible for on behalf of the people living here. Most of the sample of medicine records we looked at appeared to be in order so that there were clear records about the medicines people living in the home need and had taken. We pointed out a few examples where records were missed or where we could not tell the actual dose of medicine given. There was a recent example where an agency nurse had failed to give one person some medicines due at 8am on two days. We saw that the home had taken action to deal with this. The exception was that some of the records about creams and ointments care staff had applied were made inconsistently so that we could not always tell if and how the prescribed treatments were used. We looked at some of the containers of these kept in peoples bedrooms. In some cases these were not properly labelled or dated so that stock could not be regularly changed according to good practice to help reduce risks of Care Homes for Older People Page 17 of 42 Evidence: contamination. This had been reported and a requirement made at the inspection in February 2008, so improvements we saw at an inspection in August 2008 have not been sustained. We found that staff were not aware of the anticoagulant patient safety alert that the National Patient Safety Agency has issued with advice for social care providers to help prevent potential harm to people taking this type of medication. Some of the arrangements needed improvement such as having dose changes confirmed in writing and using the standard oral anticoagulant therapy book. Medicines were stored safely but improvements are needed in the main medicine storage room. There were areas of bare plaster on the walls and there was a dirty carpet on the floor. There were no handwashing facilities. These issues need attention as this is a clinical area that must be kept clean. The temperature of the room should be monitored to make sure this is safe for storing medicines. Arrangements for storing medicines on the first floor also needed improvement as the cupboard did not have a strong enough lock or hinges or taking into account the number of medicines kept here. The medicine trolley for the first floor was very full which made selecting the right medicine more difficult. The arrangements for stock control of medicines needed some attention. Records showed some medicines had been out of stock during the current four week cycle and staff told us running out of stock was sometimes an issue. This is a risk to the health and well being of people living here. On the day of the inspection the medicines people needed for their treatment were in stock. The new clinical lead nurse had begun to put in place systems to prevent this happening in future. There were also excessive stocks of other products particularly dressings and creams with examples of items dispensed in 2007 and others that were no longer prescribed for use yet the stock was retained. There was also a lot of stock still awaiting disposal. There were many examples where containers of medicines did not have the date of opening written on despite the Pharmacy putting a specific label for this on many packs. This is good practice to make sure medicines are used within the recommended timescale to prevent contamination or reduced effect. There were safe arrangements for storing and recording controlled medicines. Sample checks we made of these medicines agreed with the recorded stock balance. There were no regular recorded stock checks as are needed to make sure that these medicines are always properly accounted for. For liquid medicines it would be clearer to check stock balances if each bottle was recorded on a separate page so that this can be checked at the completion of every bottle. Care Homes for Older People Page 18 of 42 Evidence: Since the last inspection we saw evidence that all medicines in the home were now disposed of following the correct process. There was no up to date medication policy and procedure available. This is necessary to make all staff aware of how the company expected medication to be handled in a safe way. The manager told us the PCT pharmacist was helping to rewrite this but ultimately the home need to write the policy themselves. The inspection has shown that clear policy and procedures were needed so that everyone was aware of what was expected of them and their competence could be monitored against this. The CSCI Pharmacist concluded that there are some safe arrangements in place for the management of medicines although there are some weaknesses that need addressing in order to help reduce risks with medication for people living in this home. Care was mostly delivered in the privacy of residents own rooms, however we did witness staff being very attentive and mindful of needs. We spoke to staff who all were able to discuss residents care knowledgeably. Staff were interacting very respectfully and politely with residents. We observed some carers helping one particular resident to walk. They were very mindful of the persons choice, capabilities and needs throughout the process as per their care plan. Three residents said that they were enabled to be as independent as possible. Some of the care plans that we inspected contained information regarding the persons chosen arrangements regarding the end of their life when the time came. The home was planning to introduce specific End of Life care plans to outline the wishes of the resident for such an eventuality, and where possible to take into account those of the family. These plans would take account of advanced wishes, holistic care, treatment options and wishes regarding hospitalisation if necessary, and pain management. One of the care leaders was undergoing palliative care training through the CHST, and there were three other carers set to do End of Life care training with the team as well. One member of staff said that they felt that they personally let residents down at the end of their life and that they needed more support in this area. Care Homes for Older People Page 19 of 42 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home have the opportunity to remain socially active and exercise freedom of choice, and have a nutritious diet that offers choice and variety. Evidence: There was no designated social activities coordinator employed in the home and we recommended to the manager that one be appointed. A member of staff was undergoing specific training with the Care Home Support Team in Activities in a Care Setting. A monthly activities programme was on display, a copy of which had been distributed to all residents. A programme of activities included games, bingo, quizzes, music afternoons, and exercise classes. Special occasions were celebrated and observed, such as birthdays, anniversaries and festival dates. Outside entertainment had been brought in for the residents, and the home had links within the local community with the church, school and a senior citizens club. On this occasion we found that staff were adopting a more targetted approach towards those residents who may not be able to easily access group activities. Staff were Care Homes for Older People Page 20 of 42 Evidence: spending more quality time with individuals, with general chatting, sharing memories, reading books and letters, and manicures. The homes AQAA stated that social care plan forms were issued to prospective residents at the pre-admission stage in order that information could be obtained regarding their past interests and hobbies, likes and dislikes, and favourite television programmes. One family told us that they had found this very reassuring and that the home had taken the trouble to get to know the person. However on inspection, the inclusion of these social plans was inconsistent and staff had not taken action to develop full social care plans in every case to meet individual needs. Existing plans were not well detailed, showing only that the individual needed encouragement and was to be offered chance to join in. Staff needed to help people to build on their interests and past hobbies. However, the home was taking action to encourage resident participation in social engagement, and records of participants were being kept to allow staff to monitor individual circumstances. We were told that the purpose of this was so that more individual programmes could be developed if necessary to suit. We saw a bingo session on the first day of the inspection with lots of residents joining in. There were regular religious services held in the home for residents and at present these included a service for two particular denominations. One resident often went out to attend her regular chapel with her daughter. The AQAA told us that a regular knit and natter group was held for those who were interested, and art classes were also held. Residents have stated that they would like to have more mini bus trips out, which the manager is endeavouring to accommodate. A number of residents told us that there were only sometimes activities that they could join in with, whilst a good number of residents told us that the home always provided activities according to choice, with some saying how much they enjoyed them. The homes AQAA confirmed that visitors could stay for a meal with their relative if they wished, although the home had decided that this was an area that they could do better on the basis of seeking visitor views. One resident told us that they received lots of visitors in their room. The home seemed to be very welcoming towards visitors and we were able to speak to three of them during our visit. Each visitor said that they felt very welcome in home and told us that they had access to information and were kept well informed by the staff. One told us that she could bring her dog in to visit Care Homes for Older People Page 21 of 42 Evidence: and that staff made drinks for the family when they came in. Visitors confirmed that staff always respected their relatives choices. We witnessed staff being very mindful in this area, and were heard offering lots of choice respectfully during their interactions with people. Residents rooms contained personal belongings, some more than others. Some had brought in their own television. The home provided a hairdressing salon with regular appointments for residents if they wished. The home provided up to date information on mental capacity and decision making if anybody needed this. Two residents told us that they never felt restricted and could do as they liked. Both were happy to be maintaining some independence. One of them said that residents were treated as individuals. Staff told us that residents were able to bathe at their preferred time of day, some choosing to have it at night. One resident told us that he had been asked by a carer not to ask for drinks at night. This was not in line with the policy of the home and was reported to the manager. Residents had a good degree of choice with their food and we received some excellent comments from them about it. One visitor told us that their relative always enjoyed excellent food. The homes AQAA stated that alterations had been made to the menus at the request of residents, with the introduction of pasta dishes as an example. Menus showed at least two choices for lunch, with cooked breakfasts available and hot and cold choices for supper. We spoke to the cook who was very informed about individual likes and dietary needs of the residents. Nutritional assessments and input from the Speech and Language Therapist (SALT) had resulted in beneficial alterations to some special diets. We saw freshly prepared and nutritious meals that were well proportioned and well presented. Home-made cakes had been prepared including a diabetic substitute. The dining rooms were laid appropriately with condiments, table cloths, drinks and floral decorations. Catering records were in order and the kitchen was clean and organised. Care Homes for Older People Page 22 of 42 Care Homes for Older People Page 23 of 42 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home are very reassured by the homes procedures for dealing with complaints and for safeguarding their interests and preventing abuse. Evidence: The home had a clear policy for addressing complaints and concerns, which was made available to all interested parties. A recent satisfaction survey showed that people felt reassured by the way in which the home addressed concerns. One relative told us that The manager adopted a very open approach to listening and addressing concerns, whilst a staff member told us The manager had an open door and was always ready to listen. Residents and other visitors all confirmed their confidence in the manager and staff to deal with their concerns should they have any. A record of all complaints and concerns received was maintained. This included records of correspondence, and each record linked to an audit with action plans to address any issues. These in turn were linked to staff supervisions and could be cross referenced easily. The records showed that the number of complaints was evidently reducing. There were clear policies regarding safeguarding the interests of vulnerable residents, and there were written policies for dealing with residents wills and gratuities. Staff had received a full days training in safeguarding vulnerable residents from abuse Care Homes for Older People Page 24 of 42 Evidence: from the groups training provider, and records showed that induction training for new staff also included this training. The home manager had received an enhanced level of safeguarding training and had also been trained in the Mental Capacity Act 2005 (MCA), and was doing Deprivation of Liberty Safeguards (DOLS) training the following week with the Local Authority. The home had obtained up to date DOLS and safeguarding information from the Department of Health. We spoke to staff about their knowledge of safeguarding vulnerable adults and all demonstrated their awareness of abuse and safeguarding procedures. There have been instances where concerns have been raised over certain staff actions and practices with the disciplinary procedures implemented. The home home has shared this information with CSCI and other relevant organisations, such as the Nursing and Midwifery Council (NMC) and has taken any appropriate steps for the safety of vulnerable residents. One resident told us that she had never heard a bad word from staff and that she felt safe here. A visitor told us they had complete confidence that their relative was safe in the home. Care Homes for Older People Page 25 of 42 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Despite room for continued improvement in the fabric and safety of the environment people living here are generally provided with accommodation that is suitable to meet their needs. Evidence: The home has now employed a new maintenance person solely for the Grange in order that maintenance issues could be dealt with more efficiently. Maintenance records were kept, which demonstrated that regular checks were carried out around the environment to perform safety checks and identify and address any issues. Communal rooms on Oakdale, Beeches and Yew Tree floors had been redecorated and two new overhead bath hoists had been fitted on Oakdale and Yew Tree. Bedrooms were being redecorated as they became vacant. Bathroom two on the top floor of the home was in a poor condition and had still not been refurbished despite the manager saying at the last inspection that this was going to happen. On this occasion the manager said that it was on her wish list that had been sent to the proprietor. The bathroom was not in use by any residents and there were adequate other assisted bathing facilities for the interim on this floor. Storage remained a problem in the home, although lounges were much clearer on this occasion. Care Homes for Older People Page 26 of 42 Evidence: There were areas where wall paper was peeling off the walls and these included the Kingfisher lounge and in the corridor opposite the Woodpecker lounge. The fire door outside this lounge had no intumescent strip and would be highly unlikely to form a seal in the event of fire. Woodwork in many areas was scratched and damaged from wheelchairs and looked unsightly in places. One particular residents room appeared to receive less attention than others and was more sparse. We were told that this resident had previously lived a very basic existence before coming into the home and had had no normal life comforts that one might expect. The resident chose to live like this and evidently had diverse expectations about life and was not receptive to interference from staff. Staff were doing their best to respect and manage this. However the ensuite flush handle appeared broken on the toilet cistern and there were no bath taps. The manager could not answer why these were not on the bath, saying that the bath was not used and never had been. A member of staff told us The home is tired and needs redecorating, whilst another said it needed modernising, and that The home is old and tatty and things do not get mended. They also went on to say that The standard of cleaning let the home down. A resident particularly mentioned that her room was kept nice and clean however. One visitor told us that it was the cleanliness and freedom from any odour that had impressed them when they first visited here. The housekeeping staff performed regular carpet shampooing There were no unpleasant odours apart from a very mild and transient urinary odour upstairs on the afternoon of the first day of this visit. The laundry room had three washing machines, two of which were capable of sluicing and disinfecting any foul laundry. The laundry was busy with a large amount of clothing and items going through. There were a large number of unnamed items on a rail awaiting return to the rightful owner, although these were proving difficult for staff to identify in some cases. There were handwashing facilities in here and around all areas of the home, with liquid soaps, sanitising hand gels, aprons and gloves provided. There was a small sluice on first floor. The home had a contract for the disposal of certain grades of clinical waste, however did not have one for the disposal of incontinence waste; this was being placed into the household waste. We have strongly recommended to the provider that the home has a contract for disposal of this type of waste with a licensed contractor. In response to this the provider informed the local council of the homes practice in this area who had reportedly never raised any objection in response. Care Homes for Older People Page 27 of 42 Care Homes for Older People Page 28 of 42 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home receive care from a competent work force who undergo full pre-employment checks and who are supported to train and develop professionally. Evidence: The staff team had undergone some significant changes over the past year with some senior staff having to leave. This had resulted in low morale and uncertainty for some, and the home had tried to support residents and staff through the difficult period. A lot of agency staff have been used, although the home has tried to get consistency for the residents by requesting the same people as much as possible. Changes to the management structure had taken place with the appointment of a Clinical Lead Nurse and two Residential Care Leaders (RCL). Staff were allocated into different areas of the home each week, with a leader in each area to provide leadership and to monitor the skill mix. The staff rota showed that there were two nurses plus nine carers in the morning, and one nurse and six carers in the afternoon and evening for the residents requiring nursing care. There were two Residential Care leaders plus five carers during the morning, with one RCL and four carers in the afternoon and evening for those residents requiring personal care. There was one nurse and four care staff on duty Care Homes for Older People Page 29 of 42 Evidence: overnight for all residents. There was a team of ancillary staff to support the care and nursing team that comprised of laundry, housekeeping, catering, maintenance and administrative staff. When we spoke with staff they were very informed and sensitive to the needs of the residents. Isolated members of staff told us that they did not think there were enough staff to meet the needs of the residents. Some also said that there was a lack of communication between the staff. Others said how hard many of them had worked to improve things at The Grange, and about how much they loved their work. A much better team collaberation was reported by some, with the previously reported divisions within staff teams being erradicated. Comments from residents were very favourable about staff. We received comments such as staff are very kind and respectful. One particular resident said that they could not find a better home, and that the staff were very caring. Three visitors all spoke very well of staff saying they were wonderful, attentive and caring, and that all were friendly and knew the residents well. They spoke of having great confidence in the home, its manager and its staff. Twenty five carers had achieved a National Vocational Qualification in care (NVQ) at level 2, and there was an expectation that all care staff would do the NVQ after being with the company for six months. A long serving core team of staff continued to exist and home was now building up a bank of its own staff. A lot of successful recruitment was reported to us. We inspected recruitment files for three more recently appointed care staff. Application forms provided an employment history, and where gaps in this history existed these had been explored during interview. Two references, one of which was from the previous employer, had been obtained, and proof of identity had been confirmed. Where applicable, verification of why the worker had left their last place of work (if it had been with vulnerable adults) was sought. The correct Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks had been carried out before employment had started. Medical fitness had been confirmed. Offer letters and terms and conditions of employment had been issued, and each member of care staff had been issued with a copy of the General Social Care Council Code of Conduct. The manager was taking steps to monitor any high levels of sickness amongst staff. Further to the discovery last year that two qualified nurses had failed to maintain their registered status and subsequent eligibility to practice, the manager had implemented a new checking system to ensure that all qualified nurses registration details were up Care Homes for Older People Page 30 of 42 Evidence: to date. The manager acted as the homes designated training coordinator and immaculate training records were maintained. Certificates of achievement were on file for each worker. Training had been delivered to staff in dementia care, nutritional care and assessment, managing challenging behaviour, falls and risk assessment, care planning, continence management and the MCA. Staff also received instruction in mandatory topics covering fire safety, manual handling, first aid, and food hygiene. They were also scheduled to receive training in equality and diversity issues through a distance learning course with a local college. Three staff were being trained to become the homes appointed dementia link workers, and all nurses were attending a wound management study day through the Primary Care Trust CHST. They had also provided training to nurses on gastrostomy practice, syringe drivers, palliative care and venepuncture. Records showed that new workers were assessed for the level of induction training that they needed. An assessment of competencies had been done by the manager with a tailored induction training programme provided to suit their needs. All staff had worked their way through the Common Induction Standards (CIS) for care workers. Induction programme results had been reviewed and where any gaps in the workers knowledge existed, additional learning opportunities had been provided. A number of staff told us that training was excellent for staff. One said they had received a good induction with good support from the manager, and very good ongoing in-house training. Several commented on the large amount of support they had recieved from the registered nurses and the lead nurse in particular. One senior carer told us that they had felt inspired by the training they had received, and really felt that they were given the scope to develop. Care Homes for Older People Page 31 of 42 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Despite some areas needing more attention, the continued improvements to the management systems in place here have ensured that the interests and health and safety of the residents living in the home are safeguarded. Evidence: The manager of The Grange Nursing Home is not a registered nurse but she has achieved the Registered Manager Award and the NVQ level 4 in Care. She has recently been registered with CSCI for her role. It has been vital to this registration that a full time clinical lead nurse be appointed, and the recent arrangements to fulfil this have had to be reviewed with a new appointment made to carry out the role. The manager said it was her intention to meet daily with the clinical lead person. She recognised that communication would be vital in terms of understanding the residents and their needs, plus any changes affecting their care and circumstances. The manager was defining clear lines of responsibility within the staffing structure. Care Homes for Older People Page 32 of 42 Evidence: A regular visitor to the home told us that the manager provided excellent support and was a fine example of what leadership is all about. One resident told us that the management and staff were most co-operative, very caring, and that the home was a professionally run establishment. Some staff said that the manager was innovative and forward thinking and they were supporting her to change old methods of working that no longer met with the needs of the home and its residents. The manager had endeavoured to drive improvements in this home and eliminate any poor practices. Some staff had proven resistive in this process and this in itself had posed significant challenges to the management of the home. However many of the staff demonstrated a very clear commitment towards driving improvements at The Grange. One member of staff commented that there had been lots of improvement under the new manager. The AQAA was completed to a good standard, however the list of policies and procedures was incomplete, with many policies showing that they had not been kept under review. The home had reportedly received a lot of positive feedback from Doctors and Social Workers about the homes performance and about the improving organisation of the home. An annual satisfaction survey had been issued in 2008 which involved residents and their visitors, with the views of visiting healthcare professionals sought as well. The survey results had been audited and an action plan devised to address different areas. This had been fed back to staff and the results had also been made available in the homes information folder. Meetings were being held for residents, their families, and for staff. Recorded minutes of these were maintained. Minutes showed that there was appropriate sharing of information with the NMS (National Minimum Standards) and KLORA (Key Lines of Regulatory Assessment) discussed with staff, and that residents had the opportunity to have a say in how their home was run. Records confirmed that there were some regular internal auditing arrangements ongoing, and the manager had a wish list to provide to the proprietor annually for areas identified for improvement in the home. Some residents had placed money in the main safe in the managers office for safekeeping. Each individual had their own financial records that reflected any transactions and running balances. We carried out random checks on two such arrangements, each of which was correct. We saw evidence of signatures from some family members, or even the resident in some cases, to acknowledge returns of money or valuables. Receipts for any expenditure were kept and could be cross referenced against the separately maintained financial record. Care Homes for Older People Page 33 of 42 Evidence: The staff supervision matrix confirmed that a formally recorded supervision programme had not been delivered for many months. The manager had still not decided upon key staff to help her deliver the programme. Despite this there were records of supervision for new staff at the end of their probationery periods, and the residential care leaders had carried out some group supervision work. Appraisals had not been conducted either, but the manager planned to build these in to the supervision programme annually. The home had written policies and procedures in relation to the promotion of the health and safety of the residents, visitors and staff, and associated training was provided for staff. Records showed us that regular checks had been carried out on the fire safety systems, including the fire alarms, smoke detectors and emergency lights. Fire safety training had been delivered to all staff and this had incorporated unannounced fire drills and evacuation procedures in the event of a fire, as well as basic fire safety procedures for the home. A full practical evacuation training session was planned for staff over three forthcoming dates. The necessary safety checks and maintenance of utilities and equipment had been undertaken in a timely fashion and the associated records were kept in these areas. Hot water outlet temperatures were being checked for safe temperatures each month. Some hot outlets were recorded as low as 22 degrees Centigrade on occasions, which posed a slight doubt about whether staff were carrying out this task properly. If they were, then it posed a degree of doubt over the veracity of a previous statement given to us, that hot water was stored above 60 degrees Centigrade and distributed at over 50 degrees Centigrade as a control for Legionella prevention. The manager agreed to look into this more closely. A large proportion of the staff group had been trained in basic first aid, and first aid facilities were widely available throughout the home. Accident records were being maintained and any incidents were being regularly audited. Any evidence of patterns was being identified with action taken to address any concerns or issues. A visiting healthcare professional had raised their concern with us about the homes security on occasions, as they had found the front door often open with the receptionist not there. During this visit the front door was unlocked but the receptionist was mostly present. The manager confirmed that the door was always locked at five pm. Care Homes for Older People Page 34 of 42 Care Homes for Older People Page 35 of 42 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 36 of 42 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 The Registered Manager must ensure that care plans are revised and updated on the basis of changes identified during reviews. This is so that plans remain accurate to the residents circumstances, and their needs can continue to be met appropriately. 31/05/2009 2 7 15 The Registered Manager must ensure that detailed care plans are devised that accurately reflect residents health and care needs, including the involvement, advice and treatments of other healthcare professionals. This is so that staff have access to relevant information to meet residents needs consistently. 31/05/2009 3 8 13 The Registered Manager must ensure that full 31/05/2009 Care Homes for Older People Page 37 of 42 assessments are carried out in those cases where bed rails are used without soft bumper pads being in place. This is so that risks of injury from entrapment can be identified, with action taken to reduce or eliminate any risks. 4 9 13 When any medicines are 18/05/2009 prescribed to be administered when required or with a variable dose make sure there are always clear written guidelines for staff in how to reach decisions about administration for each person and medicine in accordance with the provisions of the Mental Capacity Act 2005. This will help to make sure there is some consistency for people to receive the correct levels of medication in accordance with their needs and planned actions. 5 9 13 Review and update the 31/05/2009 medicine policy and local procedures (including homely remedies) and make sure this is read, understood and implemented by all staff. This is so that all staff have precise direction about the way medicines are safely managed and handled in this home. Care Homes for Older People Page 38 of 42 6 9 13 Where staff support people 18/05/2009 to look after and administer their own medication the medicine records must also include when each medication and quantity is actually given to people to look after, as well as records of regular monitoring checks that staff make that people are using their medication correctly. This is to help make sure people receive the right medicines and are taking the correct levels of medication. 7 9 13 When any medication is administered to people who live in the home it must always be clearly and accurately recorded. (This particularly relates to records for prescribed treatments applied to the skin). This is to help to make sure people receive their prescribed medication correctly and to help reduce risks of mistakes. 18/05/2009 8 19 23 The Registered Manager must ensure that the necessary repair or upgrading is carried out to the designated fire doors. This is to ensure that all fire doors are equipped to protect residents by containing fire and smoke in the event of a fire. 15/05/2009 Care Homes for Older People Page 39 of 42 9 38 13 The Registered Manager must provide information to CSCI to confirm the risk reducing measures adopted for the control of Legionella. This is to determine whether appropriate controls are in place for the health and safety of the residents. 31/05/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 9 Arrange to use the standard yellow anticoagulant book and for dose changes of anticoagulants to be confirmed in writing by the prescriber on all units as detailed in Patient Safety Alert 18 from the National Patient Safety Agency. Review the times and arrangements for administration of medicines to help make sure that all doses are administered within an acceptable period of the stated dose time and to provide safe intervals between doses throughout the 24 hour period. This is to help make sure that people living in the home receive the correct levels of medication and are not at risk or discomfort because of wrong dose intervals. Write the date on containers of medicines when they are first opened for use to help with good stock rotation in accordance with the manufacturers or good practice directions and to help with audit checks. Make regular stock checks of all controlled drugs and keep records of these checks. Make arrangements to review and improve the storage arrangements for medicines so as to reflect best practice guidance and to deal with the shortfalls identified at this inspection so that all medicines are always stored safely and do not present a risk to anyone in the home. Record the temperature each day in the main medicine storage areas to make sure this is within the safe range for keeping medicines. The Registered Manager should ensure that some Page 40 of 42 2 9 3 9 4 5 9 9 6 9 7 19 Care Homes for Older People decorative improvements are carried out in deteriorating communal areas and corridors. 8 26 The Registered Manager should ensure that a licensed contractor is used to remove incontinence waste from the home. The Registered Manager should ensure that the homes documented policies and procedures are reviewed and updated. The Registered Manager should ensure that a formal staff supervision programme is delivered at least six times in a twelve month period. 9 33 10 36 Care Homes for Older People Page 41 of 42 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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