Inspection on 13/01/06 for Wentworth Grange

This inspection was carried out on 13th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wentworth Grange 16/12/08

Wentworth Grange 16/01/07

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Wentworth Grange Riding Mill Hexham Northumberland NE44 6DZ Lead Inspector Suzanne McKean Unannounced Inspection 13th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wentworth Grange Address Riding Mill Hexham Northumberland NE44 6DZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01434 682243 01434 682009 Underwood Hall Ltd Mr Jeffrey Lee Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user is category MD(E). No further admissions can take place in this category without the prior agreement of CSCI. Date of last inspection Brief Description of the Service: Wentworth Grange is a detached purpose built home situated within its own grounds close to the centre of the village of Riding Mill. A single storey extension was previously part of the old home building and is now a standalone facility but remains part of the registration. There are extensive landscaped gardens surrounding the buildings complete with water features and several sitting areas. There is a car park to the front of the building and access to the separate building is via a road around the main building. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over five hours by two inspectors, Suzanne McKean and Jim Lamb, both of whom have visited the home on previous occasions. The manager was on duty during the visit and assisted the inspector with the inspection process. Nine residents were spoken to during the visit and four relatives; the inspectors also spoke to nine of the staff in process of the inspection visit. Records examined included, four care plans, training records and the records for complaints as well as the health and safety, accident and kitchen records. There were three requirements and no recommendations identified during this inspection. What the service does well: What has improved since the last inspection? There were no requirements or recommendations identified during the last inspection. The residents are now accommodated in the new building which is very pleasant and has been built to high specification. Residents spoken to were very complementary and happy with their bedroom and communal areas. Some interactions between the staff and the residents were very positive and took into account the principles of choice and independence. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 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 the following standard(s): 123456 The homes Statement of purpose needs to be reviewed and up-dated to take into account the new premises. Contracts are given to residents as necessary. All prospective service users are invited to visit the home and are provided with enough information before they make a decision stay, as are their relatives and representatives. Residents are appropriately assessed prior to moving into the home. Intermediate care is not provided. EVIDENCE: Details of the extra charges and what these are for, are in the contract given to service users and are agreed prior to their admission. The homes Service Users Guide contained the full range of information required. Two service users interviewed confirmed that they had been given copies of the guide. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 9 The homes Statement of Purpose needs to be reviewed and up-dated to include the accommodation and communal space provided within the new build. Four service users’ files were checked and on each were a copy of a full needs assessment carried out by the referring Care manager, for those service users who are self funding, the registered manager completes a detailed preadmission assessment. Care plans contained a range of appropriate information and the service user interviewed confirmed they were involved in drawing up both these initial assessments and the home’s subsequent service user plans. All prospective service users and their representatives are invited to visit the home to meet other service users and staff prior to admission to the home. The service users interviewed said their needs were met and they were happy with the care offered to them. Care plans were checked and staff members interviewed. These confirmed that a range of specialist services was provided to service users. Staff interviewed had had a range of relevant training and experience. Intermediate care is not provided. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 The home has comprehensive care plans. Individual care planning is undertaken and the care is being delivered in line with these plans. The residents are having their health care needs met. Staff treat residents with respect and maintain their privacy when they are caring for them throughout their daily life. There is a procedure in place for administering medication which was being generally complied with some gaps in medication records were evident. There is a policy in place for those who may require terminal care and staff were aware of its contents. EVIDENCE: Four care plans were examined, they were completed effectively and in good detail to allow the staff to used them to plan the care to be provided. A variety of assessment tools are being used, and the care plans are being reviewed on at least a monthly basis. The Manager Mr Lee undertakes monthly random audit. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 11 The home is registered to provide Nursing care and the home has the necessary equipment to provide for the needs of the current residents. This included a number of intermittent pressure-relieving mattresses and patient hoists. A skin integrity assessment tool is used and all service users are assessed formally for their nutritional status. Residents are provided with services available to the wider community for example chiropody, dentistry and other therapeutic services according to assessed need. Residents are weighed regularly and staff make changes in the care provided to take into account any changes. An examination of the procedures used to administer medication was carried out as well as tracking of one service users records. These records and systems were complete and there was evidence that the nursing staff were aware of the need to manage the medication systems effectively. However some gaps in the medication records were noted and this must be investigated and staff reminded of the need to complete the records accurately. Those residents interviewed during the visit confirmed that staff knocked on their bedroom doors prior to entering and that they felt that they were offered privacy during personal care. Any examinations by medical or nursing staff are carried on in the resident room. Appropriate procedures are in place for the care and comfort required for service users who are dying, this includes terminal care. Service users (unless medical reasons prevent this) are able to spend their final days in their rooms, surrounded by their personal belongings, family and friends. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 12, 13, 14, 15 Residents are satisfied with the flexibility of their routines for daily living and activities, which are appropriate to meet their cultural, social, religious and recreational interests and needs. Arrangements for residents to maintain contact with their family and friends and the local community are suited to each individual’s needs and vary accordingly. The food being served is being prepared safely by knowledgeable staff and offers choice to the residents. The home offers the resident a balanced diet and there is sufficient quantity of both food and fluids to meet their needs. EVIDENCE: There was evidence that each service user has the opportunity to participate in community-based activities, including in-house social activities. The home has use of a community mini bus for outings to local places of interest. The staff have arranged with the publishers of the local newspaper to provide a weekly copy of their spreadsheet on audiotape. This is good practice. All service users are supported to maintain very close links with their families. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 13 All are able to choose who they want to see and when. There was evidence that daily routines promote independence, choice and freedom of movement. Regular service users meetings take place and these are well attended. The inspectors observed staff interacting in a sensitive and respectful manner with service users. The Home’s menus are based on the known likes and dislikes of the service users. At least three hot meals are provided on a daily basis. The menus appeared varied and nutritional, special diets are provided as needed. The service users said that the food was very good and they confirmed that a choice is always available. The kitchen was found to be well-organised, clean, and tidy with ample stock levels including fresh vegetables and a good selection of fruit. The catering staff maintains appropriate checks as required. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 16, 18 The home ensures that the residents and relatives are made aware of the complaints policy and that it is available in a variety of places. There is a system for managing and dealing with complaints, which ensures that they are investigated and action taken to address any issues identified. The home protects the residents from abuse by having a policy in place and by training staff in how to recognise and react if abuse is suspected. EVIDENCE: The complaints policy is in the service user guide and is displayed in the home. The residents were clear about the complaints procedure and said that they would not be worried about speaking to a member of staff if they had any concerns; they also said they would speak to Mr Lee, the Manager when he tours the home as he frequently did. Records of recent complaints were examined and competed in detail. There have been two anonymous complaints made directly to the CSCI since the last inspection one of these have been investigated by the home and the issues raised by the other were considered during the inspection process. Action has been taken by the home to address any issues raised and ongoing dialogue is ongoing with the home to regarding them. The home has policies and procedures in relation to the prevention of abuse and whistle blowing; the staff are trained in these areas of practice, which is included in the induction programme and the ongoing in house training programmes. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 19, 26 The home provides excellent facilities and is suitable to meet the collective needs of the service users in a spacious, comfortable and homely way. The home has policies and procedures for the maintaining of a clean and hygienic environment, and the control of infection, which are known by the staff. EVIDENCE: On the day of the inspection the home was clean, well decorated and well maintained. The service users interviewed did say it was homely and comfortable. The grounds were tidy, safe, highly attractive and accessible, some areas are yet to be landscaped, and the inspectors were informed that they are awaiting the delivery of topsoil. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 16 The fire service and the environmental health department had made visits to the home. Requirement made by these organisations had been met prior to the registration of the home. The home does have an appropriate amount of sitting, recreational and dining space. There are sufficient rooms for a variety of activities to take place. Service users can see visitors in private in their own rooms and the dining areas are large enough to cater for all service users. There are smoke-free sitting rooms. Furnishings and fittings were domestic in design and in good condition. The lighting was sufficiently bright and also domestic in design. The home does have a sufficient number of baths, showers and toilets. These were close to bedrooms, lounges and dining areas and the doors had privacy locks. Room sizes exceed the minimum required. Room dimensions were such there was space on either side of the bed when necessary to enable access for carers and specialist equipment. Service users’ bedrooms checked all had opening windows. The rooms were centrally heated (under floor heating throughout the building) and the heating level could be controlled within each bedroom. All bedrooms have a telephone point. Lighting levels were sufficient and there was emergency lighting throughout the home. Water is stored at over 60°C. Valves are in situ at water outlets to ensure water is provided close to 43°C to prevent scalding. The home was clean and free from offensive odours. The laundry facilities appeared to be very well organised. The washing machines have the specified programme to meet disinfection standards. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The home is staffed with appropriate numbers of staff and there are qualified nurses on duty in sufficient numbers to meet the needs of the residents. The staff are recruited and selected using a system, which ensures that they are able to care for the residents and have not been identified as posing a risk to their welfare through Criminal Record Bureau and the Protection of Vulnerable Adults List. Training is provided to the staff covering both statutory and clinical issues and is up to date except for fire training and the POVA training, both of which are planned. EVIDENCE: Staff records examined were completed in line with the company policies and procedures, including two references and a completed application form. The requirement to have a CRB and POVA check in place is applied to all of the staff in the home. The training records maintained by the Training officer to allow her to plan for training was examined, it was very clearly maintained and offered a good system. However, although there is evidence of a significant amount of training in both statutory and clinical areas of practice not all staff are receiving training in line with the company policy and statutory requirement for fire training. There is Protection of Vulnerable Adult training planned. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 18 Staffing rotas showed that the Manager is ensuring that enough staff are on duty to meet the staffing levels set down prior to the change to the CSCI without reduction. It was noted that when sickness and staff holidays occur it is usually covered by home staff. Late reporting of sickness does occasionally result in fewer staff being on duty for short periods. On the day of the visit there were two qualified nurses on duty all day, five carers in the morning six in the afternoon and four in the evening. The Manager was on duty from nine till five. There were sufficient domestic, catering and laundry staff on duty. Two overseas staff have recently been returned to their country of origin as they were found to be unsuitable for the employment they were recruited for. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 37, 38 The home is well managed; service users heath and welfare are promoted and protected. The environment is maintained and was safe and well organised. Resident’s personal finances are managed appropriately by the home as necessary. Staff supervision has lapsed during the recent move to the new building and there are plans to update this in line with the homes policies. EVIDENCE: Staff interviewed were clear about the their responsibilities. Staff interviewed spoke positively about the manager saying he had encouraged both staff and service users to contribute to the development of the service. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 20 Service users are informed when inspections take place and have access to inspection reports. These are also summarised and discussed in service user meetings. Copies are available for relatives/others to see The organisation has developed a range of new policies and procedures which have been linked to the National Minimum Standards. The records inspected were found to be appropriately completed, these included the fire log book, accident book, personal allowance records, Health and Safey manual, and there was information which verified that appropriate maintenance contracts for the home are in place. The individual fire training records for staff needs to be reviewed, it was dificult to ascertain when staff had received formal fire training or when it was next due. The homes training co-ordinator agreed to address this issue. The records of the residents personal finances were examined and were being kept in detial with records of money spent being signed by either the resdient their representative or by two staff. The reciepts and the recordings were present as necessary. Water storage tanks, gas and electrics will be checked annually. Finance records have previously been forwarded to the CSCI to verify that the home is viable. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 3 Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No 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 2 Standard OP9 OP30 Regulation 13 (2) 23 (4) Requirement Medication records must be complete. The records of fire training must be complete and include the contents of the training provided for all staff. All staff should be given supervision as identified in the National Minimum Standards. Timescale for action 31/01/06 28/02/06 3 OP36 18 (2) 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP30 Good Practice Recommendations The statement of purpose should be updated to reflect the current service being delivered. Protection of Vulnerable Adults training should be given as planned. Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Wentworth Grange DS0000063040.V272637.R01.S.doc Version 5.1 Page 24 - 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. 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