Inspection on 27/09/05 for Walton Grange Christian Residential Home

This inspection was carried out on 27th September 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

Walton Grange Christian... 25/09/07

Walton Grange Christian... 18/04/07

Walton Grange Christian... 27/06/06

Walton Grange Christian... 08/03/06

Walton Grange Christian... 13/12/04

Walton Grange Christian... 28/06/04

Walton Grange Christian... 24/11/03

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

CARE HOMES FOR OLDER PEOPLE Walton Grange Christian Residential Home 12 Avenue Road Doncaster, South Yorkshire DN2 4AH Lead Inspector Ian Hall Unannounced 27 September 2005 : 08.30am 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. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Walton Grange Christian Residential Home Address 12 Avenue Road, Doncaster, South Yorkshire, DN2 4AH 01302 328439 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) Mrs Sandra Walton Mrs Sandra Walton Care home only 22 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (16) of places Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13-Dec-2004 Brief Description of the Service: Walton Grange is a christian care home registered for 22 older people. The christian approach is offered to those residents for whom christianity is important. It does not intrude into the lives of others who attach no importance to religion. The home does not discriminate against potential residents on the grounds of non-belief. The building is a large victorian property situated on a wide tree lined avenue with similar proerties on both sides. Walton Grange is registered to up to six residents with Dementia. They are provided with a dedicated lounge and dining area. Staff have received additional training to equip staff to meet their care needs. Walton grange offers single room accomodaton for all residents. Ten rooms have en-suite facilities. All bedrooms are fitted with locks to enable residents to carry a key and lock their individual bedrooms. Staff have a master key to facilitate entry in case of emergency. Lounge areas and other communal spaces include a room where smoking is allowed with other areas providing television and quiet areas. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection took place over 8.5 hours and was the first of the cycle of inspections for year 2005/6 and followed a risk assessment carried out with the CSCI risk assessment tool It was the Inspectors first visit to the home; consequently an emphasis was placed upon meeting residents, relatives, visitors and the staff team. The Officer toured the whole site to understand the range of services provided there. The officer case tracked 3 resident’s files, and the records maintained. What the service does well: What has improved since the last inspection? What they could do better: Minimum numbers of staff must be on duty at all times. The Inspector contacted the manager by telephone; a cook and additional carer were then provided. An Immediate requirement notice was issued at that time. The home’s owner Mrs Walton provided copies of duty rota as required and additional staff was rota’d to work. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 6 Additional staff must be deployed to meet service users needs. Additional staff, catering, laundry, and domestic must be deployed to enable staff to fulfil their care role. There has been limited progress in improving the safety and function of the home. Health & Safety risks identified at the home require further action. The maintenance, refurbishment and redecoration need to be prioritised and demonstrated within an annual action plan. 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. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 7 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 Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 8 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) 1, 2, 3. Records demonstrate that Residents and their advocates are involved in choosing the home. The management consider the needs of others residing at the home when making this assessment. EVIDENCE: Case records examined contained copies of individual service user care assessments, plans and written contracts stating terms and conditions. Intermediate Care is not provided at Walton Grange; respite care is provided following assessment and by arrangement with the Manager. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 9 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. Records indicate that residents and their families are involved in the social, physical and psychological care planning. Access to health care professionals and health care services is provided. Staff was focussed upon meeting residents needs. Their interactions with service users were skilful, professional and with obvious empathy for the individual concerned. The numbers of staff on rota for that morning did not permit any other than basic needs to be met. EVIDENCE: Care records of 3 service users were inspected; they contained individual “needs” assessments and plans for staff to follow to meet the identified needs. The records were adequately maintained. Changes to plans and reassessment of physical and psychological needs were ongoing. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 10 None of the service users were responsible for their own medication although the facility to enable this is in place. Staff had received additional accredited training for the administration of medicines. A staff member was observed dispensing medications and assisting service users to take them. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 11 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, 13, 14, 15. The two members of care staff on duty worked hard to provide care and breakfast. This number of staff is unsafe. The resident group have a range of needs and abilities; the planned number of staff working that morning would permit basic needs to be met. Records demonstrate the plans/systems to facilitate personal choice and maintain links with the community. EVIDENCE: The two members of staff on duty were required to cook breakfast, bring it upon trays from the basement kitchen to the dining room. They were also to assist and supervise residents with their meals. Not all service users were within the dining area. They had to supervise and assist residents throughout both ground and first floor resident areas; this included toilet, bathroom and bedroom areas. One service user was dressed inappropriately. Staff attended to her clothing immediately this was brought to their attention. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 12 Additional staff, a senior carer and cook were provided after the inspector telephoned the home’s Manager. Service users had a choice of midday meal. A staff member was observed to assist and encourage residents appropriately. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 13 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. Staff were confident and competent able to respond to concerns or complaints effectively. EVIDENCE: Staff were confident in their ability to respond to any concerns or complaints that may be expressed. No complaints had been received by the CSCI. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 14 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, 21, 23, 24, 25, 26. The inspector returned on second visit to meet with the home’s owner and registered manager to discuss the list of defects identified during the initial inspection. They have agreed to provide an action plan and timescale for a schedule of works to redecorate and refurbish the home. Health & Safety remedial work had commenced. EVIDENCE: The home was clean. There were no odours. A number of individual bedrooms appeared comfortable and personalised. Bedrooms were identified that required redecoration and refurbishment. Some bed bases, mattresses and furniture were in need of replacement. Some soft furnishings and light shades were in need of replacement. Areas of carpet and floor covering throughout the home were identified to be in need of cleaning or replacement. A ramped area in a hallway presented a trip hazard. The entrance hallway had a newly fitted wooden floor surface. The Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 15 front door weatherboard had not been replaced; this potentially will allow water to damage this surface. The main dining area had been redecorated requiring finishing “touches” and blinds/curtains. A lounge and separate dining area were little used. They required decoration and definition of purpose. Equipment was being stored inappropriately within the small dining area. Toilet and bathing facilities are in need of upgrading and redecoration. The need for mobility/safety aids in these areas must be assessed and then provided. Curtains must be provided. Lighting throughout the home must be domestic in nature. There is no safe and secure outdoor area with staff having to escort individuals for a walk outside. There is an uneven patio to the front of the house. There is no other safe outdoor seating area and this was very restrictive, there is limited access for disabled people. The laundry area was dark and cluttered. It required cleaning/decoration and repair to wall surfaces. Shelving was inadequate. The hand washing/drying equipment needed replenishing. The fire exit wooden stairs were broken and full of debris. The metal fire escape had areas of rust and flaking. Brickwork / wall of a fire exit is deteriorating. Slate/ roof tiles require replacement. There was no boundary wall/fence between the rear garden and a private residence. The pool/pond in the garden requires a risk assessment and steps taken to protect residents who may come into this area. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 16 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, 28, 30. The two members of care staff on duty worked hard to provide care and breakfast. This number of staff is unsafe. The resident group have a range of needs and abilities; the planned number of staff working that morning would permit basic needs to be met. The Inspector issued an immediate requirement notice and telephoned the home’s manager. An additional senior carer and cook were provided. EVIDENCE: The two members of staff on duty were required to cook breakfast, bring it upon trays from the basement kitchen to the dining room. They were also to assist and supervise residents with their meals. Not all service users were within the dining area. They had to supervise and assist residents throughout both ground and first floor resident areas; this included toilet, bathroom and bedroom areas. One service user was dressed inappropriately. Staff attended to her clothing immediately this was brought to their attention. The dependency level of the current service user group and their needs has continued to increase; this has placed additional pressures upon staff. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 17 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) 31, 38. The home’s owner and manager have appropriate knowledge and experience. Numbers of staff on duty were below a minimum safe level on the day of inspection. Additional staff must be provided to provide cooking, laundry and cleaning services. Health & Safety, redecoration and refurbishment of the home require action. EVIDENCE: Mrs Walton has owned the home for 25 years and is experienced in Residential Care. The registered manager Mrs S Allen failed to provide a safe minimum number of staff to provide care and services at Walton Grange. Two care staff was on duty. They were providing care, cooking meals, cleaning and providing laundry services for service users. The kitchen is situated in the basement. Meals were being carried by tray to the ground floor dining area. Resident’s accommodation is located on both ground and first floor. Toilets and Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 18 bathing facilities are located on ground and first floor. The two care staff were to provide supervision and care for residents throughout the building. Cleaning substances subject to COSHH regulations were not secured safely. Fire exit from the laundry area was compromised by debris and deteriorating woodwork. The metal fire escape staircase has rusted areas. The building requires redecoration and refurbishment. There is no written action plan or schedule of work to manage this programme. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 19 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 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 1 2 3 3 2 2 2 STAFFING Standard No Score 27 1 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x x x 1 Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 20 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 12 Regulation 12(1) 13(4) 18(1) Requirement Timescale for action 1st January 2006 2. 19 13(4) 23(2) The registered person shall ensure that the home is conducted so as to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. The home must employ an activities organiser/worker The registered person shall 1st ensure that : December a) all parts of the home to which 2006 the service users have access are so far as reasonably practicable free from hazards to their safety c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. 23(b) The registered person shall having regard to the number and needs of the service users : ensure that the premesis to be used as the care home are kept in a good state of repair both internally and externally. 23(o) external grounds which are suitable for, and safe for use by service usersare provided and appropriately maintained. Version 1.40 Page 21 Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc 3. 20 13(4) 23(2) 4. 21 13(4) 23(2) 5. 24 13(4) 16(2) 23(2) The grounds of the home are insecure, have uneven paved surfaces, unguarded ramps, rusty fire escape, broken wooden staircase, roof in need of repair, a pond that is not guarded. The registered person shall ensure that : a) all parts of the home to which the service users have access are so far as reasonably practicable free from hazards to their safety c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. 23(p) ventilation, heating and lighting suitable for service users is provided in all parts of the home which are used by service users. Lighting at the home must be domestic in character, there is a lack of bedside lighting, poorly positioned bedroom lights, corridor lighting is fluorescent. 23 (d) (j)The registered person shall having regard to the number and needs of service users ensure that : d) all parts of the home are kept clean and reasonably decorated. j) provide at appropriate places sufficient numbers of lavatories, wash basins, baths and showers. Bathing and toilet facilities identified were in need of updating, refurbishment and redecoration. 23(2) The registered person shall having regard to the number and needs of service users ensure that: (e) adequate private and communal accomodation is provided for service users. (h) the communal space provided for service users is 1st December 2006 1st December 2006 1st December 2006 Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 22 6. 25 13(4) 23(2) 7. 26 13(4) 16(2) 23(2) suitable for the provision of social, cultural and religious activities appropriate to the circumstances of the service users. 16(1) provide in rooms occupied by service users adequate furniture, bedding and other furnishings, including curtains and floor coverings, and equipment suitable to the needs of service users. (see standard 24 for complete list of basic requirements). The registered person shall having regard to the number and needs of the service users ensure that : ventilation , heating and lighting suitable for service users is provided in all parts of the home used by service users. : Lighting in service user accomodation to meet recognised standards (lux 150), is domestic in character and includes table-level lamp lighting. window opening distance not to exceed H&SAW Act requirements. The registered person shall having regard to the number and needs of the service users ensure that equipment provided at the home for use by service users or persons who work at the home is maintained in good working order. (j) after consultation with the environmental health authority make suitable arrangements for maintaining satisfactory standards of hygiene at the home. (k) necessary sluicing facilities are provided. - The sluicing and laundry facilities must be clean and tidy with an impermeable floor and wall surfaces that are readily cleanable. Protective clothing 1st December 2006 1st December 2006 Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 23 8. 27 13(2) 18(1) 9. 38 13(4) 16(2) 18(1) 23(4) and hand washing facilities must be readily available. The registered person shall having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. - Care staff must be allowed to fulfill their role and duties. Additional staff must be employed to undertake cooking, cleaning, laundry, activity, and handyman duties. The registered person shall ensure that : a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. c) unnecessary risks to the health and safety of service users are identified and as far as possible eliminated. 23(4) The registered person shall take adequate precautions against the risk of fire, including the provision of suitable fire equipment; provide adequate means of escape. - fire escapes must be free of obstruction and well maintained, repair/replacemaent of wooden stairs, treat rust/ maintain metal staircase, remove debris such as leaves. Ensure window openings and COSHH regulations for storage and handling are adhered to. 1st December 2006 1st December 2006 10. Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 24 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 Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 25 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire DN4 5HZ 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 Walton Grange Christian Residential Home 20050927 Wallton Grange X00015 UI Stage 4 S8004 V177924 J55.doc Version 1.40 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!