Inspection on 26/10/07 for Grangewood

This is the latest available inspection report for this service, carried out on 26th October 2007.

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

Grangewood 01/02/06

Grangewood 14/10/05

Grangewood 05/10/04

Grangewood 08/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Beau Sejour

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Grangewood 10/12 High Street Kelvedon Colchester Essex CO5 9AG Lead Inspector Ray Finney Unannounced Inspection 26th October 2007 09:00 Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 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 Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grangewood Address 10/12 High Street Kelvedon Colchester Essex CO5 9AG 01376 570208 01376 571739 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) www.scope.org.uk SCOPE Mrs Marie Jones Care Home 19 Category(ies) of Learning disability (19), Learning disability over registration, with number 65 years of age (2), Physical disability (19), of places Physical disability over 65 years of age (2) Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability who may also have a physical disability (not to exceed 19 persons) Two persons, aged 65 years and over, who require care by reason of a learning disability who may also have a physical disability, whose names were made known to the Commission in March 2003 7th November 2006 2. Date of last inspection Brief Description of the Service: Grangewood is a large seventeenth century two storey house with an adjacent purpose built one storey building. The home is situated in the small town of Kelvedon, approximately 10 miles from Colchester. There are local facilities including shops, a public house and a post office nearby, Grangewood provides a residential service for younger adults and older people who have needs associated with cerebral palsy. Accommodation for people living in the home is provided in single rooms in the newer building. The old building, The Grange, now provides a staff sleep-in room, guest flat, family room and a training room that can be used by staff and people living in the home. The premises has been converted to meet the needs of people with physical disabilities, with wheelchair access and appropriate aids and adaptations. The home is divided into two smaller units within the main building. Each group has separate facilities, which include a living room, a kitchen and a dining area. There is a large, modern activities room that is used by people in the home. Outside the building are large, enclosed and well-maintained grounds. There are ample car parking facilities. The home charges between £767.66 and £1,140.69 a week for the service they provide. People pay extra for personal items such as toiletries, clothes, hairdressing and admission fees to leisure and recreational activities of their choice; the cost for these is normal retail prices. This information was given to us in October 2007. Information about the home can be obtained by contacting the manager. Inspection reports are available from the home and from the CSCI website www.csci.org.uk Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. The manager completed an Annual Quality Assurance Assessment with information about the home. Throughout the report this document will be referred to as the ‘AQAA’. We sent surveys out to people living in the home, relatives, health & social care professionals and members of staff and a total of 30 were completed and returned. All questionnaires contained positive responses about the home and many were highly complimentary. A visit to the home took place on 26th October 2007 and included a tour of the premises, discussions with people in the home, the manager and members of staff. Observations of how members of staff interact and communicate with people living there have also been taken into account. On the day of the inspector’s visit the atmosphere in the home was relaxed and the inspector was given every assistance from the registered manager, Marie Jones and her staff team. What the service does well: People living in the home report a high level of satisfaction with the service it provides. One relative said, “The level of care is super” another “It has a warm friendly atmosphere”. The home is skilfully managed and staff feel well supported by the management team. People living in the home are supported by staff who are well trained. There is a strong ethos of listening to people and acting on their views. People living in the home are empowered to make choices and informed decisions; they are helped to understand about rights and responsibilities. Grangewood has a good Quality Assurance system that takes into account the views of people living in the home, relatives and other interested parties. Grangewood continues to offer people opportunities for personal development and a fulfilling lifestyle. There is a good programme of activities and access to community facilities. The atmosphere in the home is relaxed and friendly and there are good interactions between people living there and members of staff. There is a robust system for the storage and administration of medication to support and protect people living in the home. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to live at Grangewood can be confident they will receive enough information about the home and their needs will be assessed before admission. EVIDENCE: Grangewood has a Service User’s Guide and Statement of Purpose to provide people with information about the home. These documents are clearly written and contain good information. A discussion with the manager confirmed that they have got the facility for translating the guide into any appropriate format for people living in the home, such as using symbols or large print. The manager said that a new service brochure is in the process of being prepared and photographs were taken in June to include in the brochure. Although there have been no new placements in the home in the last two years, the process for assessing whether they can meet a person’s needs remains robust. The AQAA states that the management team carries out a pre-assessment and develops an in-depth care profile of the person which details precise levels of support required. This information is used to prepare the individual care plan. Discussions with the manager demonstrate a good awareness of the importance of a good assessment process. A sample of records examined contains comprehensive and detailed assessments. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 9 The admission process enables anyone wishing to move into the home to try it out before they actually move in. The manager confirmed that a ‘trial stay’ is encouraged and a twelve week trial placement is offered. The AQAA states that a key worker will be assigned to the person who is moving in to support them. At the end of the trial period a review is held to decide if everyone is happy with the placement. Three people’s files were examined and all contain a signed copy of the service agreement with the home. If people are unable to sign the agreement themselves, a relative or other representative signs on their behalf. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in Grangewood benefit from a well developed care-planning system that recognises and values people’s individuality. They are supported to make decisions about their lives, participate in the running of the home and to take risks within their capacity to understand. EVIDENCE: At the time of the last inspection care plans were judged to be good and since then, the manager has continued to develop the care plans to further improve them. An internal audit visit carried out by another SCOPE Service Manager in January stated that the care plans contain excellent recording with wideranging and detailed information. The AQAA states that all care plans are individualised and identify the needs of each person in the home, who are actively involved in their individual plan. A sample of four care plans examined confirm the information provided by the home. The standard across those sampled is consistently good and they are Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 11 written in a person centred way. Care plans cover a wide range of areas including domestic needs such as laundry, daily living skills, finance, self image, choice, interaction such as social networks and sexual needs. Care plans contain good evidence that the home supports people to use environmental controls if they have limited movement. These controls help people to maintain a degree of independence by using a switch to control TV, radio, play music, access the alarm call system. Care plans also make good use of pictures where relevant. The AQAA states that care plans are reviewed at least every six months or when individual needs change and relevant amendments are made. Minutes of the annual reviews confirm that the whole care plan is reviewed in full. Individual records examined also show evidence of regular review. There is a key worker system in place and supervision records show that a review of the care plan of the person they are key worker for is carried out as part of their supervision. The home’s training planner shows that training around care planning is due to take place in March 2008. The manager says that all staff will receive this training. A completed survey received from a social care professional said that the service is good at “developing person centred approaches to care planning”. The home continues to support people to make decisions. There is a Service User Empowerment Group who have regular monthly meetings; the minutes of these meetings confirm that people’s wishes and needs are listened to and acted upon. People spoken with said they are able to make decisions. We received surveys completed by people living in the home. One person said, “I feel able to make my own decisions daily” and another, “I was able to attend empowerment training last year and hope this will continue later this year”. During the inspection visit the inspector observed people voicing their opinions and being encouraged to make choices about what they wanted to eat, what activities they wanted to do and plans for Christmas shopping. Where they are able, people were observed to participate fully in the running of the home. As at the last inspection, the home continues to have a robust process in place for assessing risks. Records examined contain evidence of comprehensive risk assessments that are reviewed regularly and if an incident occurs the risk is re-assessed and any further measures necessary are implemented. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home have excellent opportunities to participate in activities that are appropriate to their needs and they are supported to access facilities in the local community. People are supported to build and maintain relationships with their families. The people living in Grangewood benefit from a well balanced, nourishing and varied diet. EVIDENCE: The manager states in the AQAA that they offer a choice of activities and this is central to the service they provide. Staff support people to take part in both in-house and external activities of their choice. Meetings are used to obtain ideas and suggestions for the type of activities individuals require. Care plans examined contain information about activities individuals enjoy. Their educational and leisure needs and preferences are well documented, many with photographic evidence. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 13 A tour of the premises shows that Grangewood has a new activity room that is vey pleasant and modern. On the day of the inspection visit people were working on activities around food planning – using photographs to identify different food groups, then menu planning, shopping and cooking. Records show that each person has an individual weekly planner. There are a wide range of activities including art and craft, dance class, bible class, crazy art, keep fit, music group, drama, record club. Records and observations show that people are taking part in activities of their choice every day. People spoken with said they enjoy the activities and choose what they want to do. In completed surveys, two people said they “would like to do more activities at the weekends”, although people spoken with said they enjoy the activities. The activities room has a bank of computers that people use and everyone has their own email address. One person spoken with has a digital camera and attaches it to the computer to print out photos. There are three vehicles, which are used to support people to access community facilities. On the day of the inspection visit people were coming and going throughout the course of the day. The sample of care plans examined all document people’s religious and cultural needs. One person who completed a survey said, “I go to church every Sunday morning”. Records also contain evidence of relationships that the individual wishes to maintain. One relative who completed a survey said, the home has “a very good relationship with both service users and their friends and family. Always caring and considerate”. A person living in the home said, “I am very happy living here. I telephone my mum every Sunday. Sometimes she comes to see me here, sometimes I go to visit her”. There was a discussion with the manager around empowerment, which is central to the ethos of the home. People continue to be supported and encouraged to be aware of their rights and recognise their responsibilities. As at the last inspection, people continue to enjoy a varied diet with plenty of fresh, home cooked food. Lunch on the day of the inspection was fish and chips and people were observed to enjoy the meal in a social setting. People spoken with said they enjoyed the food. Records examined confirm that any special diets are catered for. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at Grangewood receive excellent personal and healthcare support that meets their needs and wishes. There are systems in place to ensure the safe administration of medication and the protection of people living there. EVIDENCE: The AQAA states that care plans are drawn up with individuals to include choice in how they wish to be supported. The plans contain information to support staff in how to meet their needs appropriately and this was confirmed in records examined. Care plans contain good background information that includes the person’s family and cultural background, their early life, their adult life and major life events. The “Getting to Know You section is well written from the individual’s point of view and contains personal quotes and good detail. The assessments of the person’s needs are comprehensive and contain a huge amount of detail about the persons preferences, routines and the things that make them feel good or insecure. The personal care needs give precise details Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 15 about how much support is required and the way that it should be provided so that staff receive guidance to ensure care is consistent. The person’s abilities are well detailed so that staff know how much or how little support is needed to help people maintain independence. Care plans are written in a positive style and there are supplementary photographs. As at the last inspection, Grangewood continues to meet people’s healthcare, physical and emotional needs. The AQAA states that annual reviews ensure service users personal and health care is being met. Care plans examined cover a range of health related needs including night time needs, mobility and transfers, communication, emotional needs, comprehensive manual handling and physiotherapy assessments. There is evidence that people’s needs for pressure relieving equipment are assessed. The plans make good use of pictures of the equipment to be used to meet the individual’s needs. There is evidence of input from healthcare professionals including guidance from Speech and Language Therapy around good practices in supporting people to eat and drink. Health care records clearly detail appointments with opticians, chiropodists, dentists and psychology. A variety of recording charts relating to people’s healthcare needs are in people’s individual files, including weight charts. There is a robust system in place for the storage and administration of medication. The sample of care plans examined all contain details of the medication prescribed for the individual, including details of what it is prescribed for and any side effects to watch out for. The administration of lunchtime medication was examined on the day of the inspection and it was observed that staff followed good practices. The Medicines Administration Record (MAR) sheets were examined and are completed appropriately and the storage facilities for medicines is suitable and secure. Individual MAR sheets contain photographs to reduce the risk of errors in administration. Discussion with the manager confirms that Grangewood continues to be aware of and sensitive to how people wish to be supported in the last stages of their lives. People’s end of life wishes are documented in the care plans. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to an effective and understandable complaints procedure that ensures that they are listened to. The home operates robust practices and procedures to protect the people who live there. EVIDENCE: As at the last inspection when the National Minimum Standard around complaints was met, the home continues to follow the SCOPE complaints policy that is in place. Documentation around complaints is good and care plans examined contain the SCOPE leaflet ‘A guide to our Complaints Procedure’. The home was part of a pilot programme for delivering empowerment training to people living in the home. The AQAA states that this is being followed up by looking at people’s individual goals, rights responsibilities and accountability. On the day of the inspection people spoken with felt confident and able to complain. Internal audits are carried out under Regulation 26 and reports are sent to us at the Commission. Regulation 26 reports contain evidence that people are given the opportunity to give feedback or complain about the service they receive. There is a procedure in place for supporting people to manage their finances. The manager explained that they carry out a risk assessment to see whether a person can manage their finances independently, with some support or if they need someone to manage all finances on their behalf. There is a robust system of checking and auditing monies spent. Records examined confirm that all expenditure is receipted and well documented. Monies are stored securely Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 17 and individually and everyone in the home has their own individual bank account. In the past Grangewood has dealt with an issue that arose around the Protection of Vulnerable Adults (POVA). The outcome of this was discussed with the manager, who handled the situation and the aftermath well by supporting all those involved. A completed survey received from a social care professional said, “There were concerns about a member of staff which were addressed and referred to appropriate services”. Staff records examined contain evidence that POVA training is carried out. A member of staff spoken with demonstrated a good awareness of responsibilities around safeguarding people. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in Grangewood benefit from a homely, comfortable environment that is well maintained and clean. There are adaptations and equipment in place that meet the needs of the people living there. EVIDENCE: The AQAA states that the manager includes in the annual budget resources to ensure regular improvements are made to the environment of the home. A tour of the premises confirms that significant improvements are in place as part of the ongoing Premises Improvement Plan. Toilets, showers and bathrooms have been refurbished to a high standard and people living in the home were involved in choosing colours and décor. A new kitchen area has been installed in one of the group areas. A further improvement has been made to the activities room, which has been moved to a larger area. This room now has a bank of computers so that people living in the home can access the internet. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 19 As at the last inspection, there are aids and adaptations in place that are of a high standard to help promote the independence of people in the home. There is good specialist equipment in place including overhead tracking for hoists. Since the last inspection eighteen new overhead hoists have been installed. (See also evidence for Standard 6.) A tour of the premises confirms that there are no odours anywhere throughout the home. The AQAA states that Grangewood employs a domestic staff team who support people in the home and staff by ensuring the home is kept clean and tidy at all times. The standard of cleanliness was seen to be good and domestic staff spoken with are conscientious about their job. A completed survey by a person in the home said, “The domestic team are very good”. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Grangewood benefit from a competent, well trained staff team, who are well supported and managed. The recruitment procedure in the home provides the safeguards that ensure appropriate staff are employed. EVIDENCE: Information provided in the AQAA indicates that 15 out of 22 care staff have achieved a National Vocational Qualification (NVQ) at level 2 or above and a further 8 people are working either to achieve either level 2 or level 3. A senior carer spoken with is completing the ‘NVQ A1 assessors award’ and is very positive about how SCOPE supports staff with NVQ training. The AQAA states that cooks are currently undertaking NVQ training relevant to their role. As at the last inspection, the recruitment process continues to be robust. A discussion with the manager confirms that people living in the home continue to be involved in recruitment by taking part in the interview process and giving their views on candidates. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 21 A sample of three staff files were examined. Records are well maintained and all the necessary documentation is in place, including photographs, references, health declarations, proof of identity and Criminal Records Bureau (CRB) checks. The AQAA states that an effective training programme is in place to ensure all staff have and achieve the necessary skills. Records examined confirm that the staff training programme is good. As well as the standard training such as manual handling, Health & Safety and infection control, staff receive other relevant training such as care planning and health related training. A high percentage of completed staff surveys received by us at the Commission made positive comments about training. These include, “They encourage staff with training”, “Attend training on an annual basis”, “Gives full training”, “Gives good training in all care needs and disability of service users” and “Up to date with all training”. The staff files examined all contain evidence of recent supervision and there is a good process in place to ensure people have regular supervision. Minutes of team meetings confirm that these take place regularly. Staff spoken with feel well supported. A survey completed by a member of staff said there are “regular staff meetings and monthly supervisions”. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in Grangewood benefit from a home that is well managed. The ethos of the home ensures that interests of people living there are central to the way the home is run. The health and safety of people living and working in the home are promoted and protected. EVIDENCE: As at the last inspection the home continues to be well managed. The manager of Grangewood has relevant qualifications, including the Registered Manager’s Award. The AQAA states that the role includes ensuring the budget is viable and keeping her own skills up to date. The manager meets the staff team on a regular basis and leads the team by example; she adopts an encourages open communications with all. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 23 Discussions with the manager demonstrate a high level of awareness of good management practices and an in-depth knowledge of the people living in the home and their needs. Staff spoken with also feel well supported. Documentation required by us at the Commission under Regulation 37 and Regulation 26 is received promptly and in sufficient detail. The manager keeps us informed of incidents and how they are being dealt with. A comprehensive self-audit is carried out monthly. A completed survey received from a relative said, “I think Marie and her staff are doing a wonderful job”. Comments in staff surveys include “Manager has an open door policy and is always available to meet with us” and “Excellent manager”. Overall records examined and people spoken with confirm that the information submitted in the AQAA around the management of the home is accurate. The home has a robust Quality Assurance system in place. The manager explained that they continue to use a variety of techniques to get the views of stakeholders, including surveys, meetings with people in the home, a robust internal auditing system and involving relatives in decision making processes. A survey fro a social care professional said the service is good at “involving service users in management of the home”. Staff records examined confirm that staff have Health & Safety training, infection control and manual handling. SCOPE has sound processes in place and records indicate that the management team implement procedures well. Records examined confirm the information provided in AQAA that appropriate maintenance checks are carried out throughout the home. Recording is good around relevant Health & Safety checks, including fire alarms, fire drills, safety equipment, water temperatures, fridge temperatures and maintenance of hoists. Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 4 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 3 4 X 3 X X 4 X Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Grangewood DS0000017835.V353763.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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