Inspection on 23/05/06 for Adel Grange

This inspection was carried out on 23rd May 2006.

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

Adel Grange 05/11/07

Adel Grange 14/12/06

Adel Grange 15/12/05

Adel Grange 07/07/05

Adel Grange 27/01/05

Adel Grange 31/08/04

Adel Grange 20/04/04

Adel Grange 17/02/04

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

CARE HOMES FOR OLDER PEOPLE Adel Grange Adel Grange Close Leeds LS16 8HX Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 23rd May 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 Adel Grange DS0000001405.V292120.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. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Adel Grange Address Adel Grange Close Leeds LS16 8HX 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) 0113 261 1288 0113 2611288 Parkfield Healthcare Ltd Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2005 Brief Description of the Service: Adel Grange is a converted, detached property situated in a residential area in Adel. There is a small area for car parking directly in front of the home. The home is located close to local bus routes. There are gardens to the rear and side of the property, which can be accessed by ramps. The home is registered to provide personal care for thirty older people with dementia. Accommodation is provided on three floors with some service areas located in the basement. A passenger lift links both floors, although one bathroom and bedroom can only be accessed by stairs. The accommodation consists of twenty single bedrooms, eight of which have en suite facilities, and five double rooms, three with en suite facilities. There are six communal bathrooms and two communal toilets. There are two lounges and a separate dining room. The kitchen is adjacent to the dining room. A notice in the entrance to the home states inspection reports is available on request. Fees for one week are £425. Residents and staff prefer the term residents, therefore this term has been used throughout the report. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A pre-inspection questionnaire was sent to the registered provider on the 5th April, this was returned on the 3rd May. Copies of staff rotas were requested with the pre-inspection questionnaire but these were not sent to the CSCI. The site visit was completed over two days. Each inspector spent eleven and a half hours at the home. During the visit the inspectors looked around the home, and spoke to several residents, staff, and the manager. Records were looked at including; residents’ care plans, risk assessments, admission assessments, food records, staff recruitment and training records, and health and safety records. Survey cards were sent to health care professionals and relatives. The feedback from relatives was generally very positive, and this has been reflected throughout the report. However, inspection visits have consistently identified that the home is continuing to fail to meet a significant number of the minimum standards. Without having up to date practices, safeguards, guidance and background training, in place, there is the real potential for things to go wrong. Ten additional visits have been made within the last twelve months. A summary of visits that have been carried out since the last key inspection in December 2005, has been incorporated into this report. What the service does well: What has improved since the last inspection? The manager has only worked at the home for a short time, and has already addressed some problems that she has identified. Staff thought the manager was good, and had already made a difference and improved the standard of care at the home. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 6 Some staff had received supervision with the manager which helps staff to develop. Even though everyone had not yet received supervision there was positive progress in this area. Staff have attended more training but because of the recording system it was difficult to establish what training staff still needed to complete. The enclosed garden at the side of the home has been tidied up, and plants and furniture have been purchased. What they could do better: Ten requirements and one recommendation are outstanding from the last visit. Several of these requirements have been outstanding since before the last key inspection in December 2005. In addition to these a further eleven requirements and five recommendations were identified. A new statement of purpose and resident guide had been written but some of the information was not accurate, and readers of the document could be misled. Care plans and risk assessments do not contain enough information, therefore staff do not have proper guidance on how to care for individual residents. Some important information about residents has not been recorded, which means their health and welfare cannot be properly monitored. Some bad care practices were seen during the inspection, this included staff trying to give an inhaler to a resident when they were eating, staff transferring a resident incorrectly and a resident not having a drink for several hours. Residents are not offered regular or a varied choice of activities and therefore do not get enough stimulation. More consideration should be given to cultural and religious needs. There are some maintenance problems with the building that need addressing. The temperature of hot water from two baths was very hot and this poses a risk to residents and must be addressed. The recruitment process is not good and staff have started working at the home before proper checks have been carried out. Some staff need additional training to help them carry out their duties properly. On occasions the home has not had enough staff working on shift. The registered provider must look at better ways of monitoring the standard of care in the home, this must also include monitoring problems that arise with the building. Requirements and recommendations can be found at the end of this report. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 7 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. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 8 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 Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 9 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): 1, 3 The statement of purpose does not accurately reflect the type of service that is provided, and readers of the document could be misled. Residents’ needs are assessed before they are admitted to the home but information is not always accurate, therefore residents may not get the right type of support or placement. EVIDENCE: The statement of purpose and resident guide have been updated; these are now a combined document. It was divided into clear sections to make it easier to read. The document stated that a range of facilities were available at Adel Grange, this included; recognition of religious practices such as prayer and contemplation, care plans which are working documents, annual reviews with social services, and good relationships with local schools. There was no evidence that any of these were available and the manager acknowledged that the statement of purpose was a description of what the home was hoping to provide in the future rather than what the home does provide. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 10 The care plans looked at included evidence of residents being assessed prior to admission. However, one resident had been described as having good sight and hearing on their assessment. However, on admission the care plan stated the resident was hard of hearing in both ears. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 11 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 Care planning and risk assessments are poor and this places residents at risk as staff are not provided with the information they need to meet the residents’ needs. These problems have been identified at previous inspections and progress is unsatisfactory. Some aspects of health care are monitored but poor care practice could have health implications for vulnerable residents. Residents are not treated with dignity and respect. EVIDENCE: The last key inspection which was carried out in December 2005 identified that the home was not providing satisfactory health and personal care. Three additional visits after the key inspection also confirmed that care plans, risk assessments and the provision of health and welfare was not satisfactory. At this inspection, care records for four residents were looked at. Each resident had a care plan and risk assessments but these did not cover all their needs. Some elements of care plans gave good information but others did not have enough information. For example, one resident had epilepsy but this was not Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 12 mentioned in their care plan or risk assessments. One resident was at risk from developing pressure sores and had lost a significant amount of weight. Assessments identified there was a risk but there was no plan of how they should be looked after. One resident had been regularly aggressive towards staff and other residents, this included hitting people. The risk assessment was last reviewed in March 2006 and stated they were settled. Eleven incidents were recorded within the last four weeks. There was no evidence to suggest that staff or management had explored reasons for or ways to manage the behaviour. The manager had arranged for a care management assessment. Some records contained conflicting information. For example one assessment stated two carers were required, another stated one carer was required. This does not provide clear guidance for staff to work with residents. A range of tools are used to measure the care needs of residents and indicate if there is a deterioration in their condition. This includes nutritional and risk of pressure sore assessments. These were being completed monthly. However, the method of recording made it difficult to know how the final total had been reached. Staff said they do not read the care plans and risk assessments. The manager confirmed that staff have not been reading the care records and did not understand the purpose of the plans. The manager had identified care plans and risk assessments as an area that must be developed. Each resident had a ‘my life’ booklet that should provide information about their past. One booklet was blank, another booklet had key information missing. Residents are weighed monthly and weight gain or loss is recorded. A chiropodist and optician visit the home when they are required. The deputy manager said a dentist was available if required but no one had received any dental service within the last twelve months. One resident had asked for a dentist on the 28th April but this had not been followed up. Two healthcare professional comment cards were returned, these did not identify any issues but some sections had not been filled in. Three residents were observed to have dressings on their legs. Staff and the manager did not know that one resident had a dressing on their leg, and staff on duty were not aware of why a dressing had been applied. Nothing had been recorded in the resident’s file. Inspectors spent three and a half hours in the lounge and dining area. During this time morning drinks and lunch was served. One resident that required additional fluids did not receive a drink, and one resident that required regular toileting was not assisted to the toilet until after they were incontinent. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 13 One inspector watched the medication being given over the two days. The way medication was offered meant that some residents had to take sweet tasting medicine whilst they were eating. On one occasion that was during the main lunchtime meal. This was refused by two residents. The medication was not re-offered once they had finished their meal and was therefore marked as refused on the medication record. The medicine was to relieve pain. One resident was not familiar with the medicine pot offered to her and consequently dropped it. A significant amount of the medicine spilt on her clothing and the remaining medicine was then poured onto a spoon. The medication record was completed to indicate a full dose had been administered. One resident was offered an inhaler whilst she was eating toast, therefore making it difficult for her to take the medication properly. Where residents were prescribed creams or specialist shampoos, the medication record was blank. There was no written evidence to show that these had been used and how often their usage was reviewed. Staff conduct at times was inappropriate and did not show respect for residents. For example, on one occasion it was announced, in the communal lounge, that it was time for toileting, on another occasion staff asked for underwear for a resident. One resident was shown into the dining room for breakfast and it was clear that grooming had not taken place before leaving their bedroom, thus compromising their dignity. Two residents had bruising on their hands but there was no record of this or any explanation of how they sustained the bruises. Unexplained bruises were raised as an issue at an inspection in November 05, December 05 and February 06. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 14 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 Relatives are happy with the standard of care provided at Adel Grange. However, without having proper systems in place to make sure social, health and personal care needs are met, there is the potential for things to go wrong. Residents do not receive a satisfactory level of stimulation; hence their quality of life is poor. The home does not meet residents’ cultural and religious needs. Mealtimes are well organised and the food is good but some residents dietary needs should be reviewed to make sure their diet is appropriate. EVIDENCE: Several different activities are provided in the home. During the inspection a sing-along session was organised. Staff said that outings and bingo sessions were provided, and an entertainer visits. Four weeks activity records for four residents were looked at. There was no evidence that any significant activity was being provided. One resident had one entry ‘singing to entertainer’ and one entry ‘enjoyed sitting in the garden’. All other entries referred to watching television. The resident’s care plan stated they enjoy 1-1 activity and outings. Another resident only had entries that referred to ‘singing’ and ‘sing-along’ or chatting to staff, reading a book, relative visited. None of the activities were out of the ordinary. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 15 The manager said the level of activity was not satisfactory and this was an area that needed to improve. Staff were unable to confirm the religion of residents and said that there were no opportunities for residents to engage in religious activities. The manager had obtained the addresses of two local churches and put these in the statement of purpose, although no action had been taken to commence any opportunities to engage in religious services. Comment cards were returned from eleven relatives. All of the comment cards were positive about the home, and confirmed they were welcomed into the home, informed of important matters and were happy with the standard of care provided. One stated there was a lack of activities and another suggested residents should go out more. Staff said that residents were encouraged to bring personal items of furniture and cherished items with them when moving in. There was evidence of this throughout the home. Some staff were seen to offer residents a choice throughout the day, about where they would like to sit and whether they wished to have a drink or meal. However, in view of the communication skills of some residents it was difficult to access the level of their understanding. Very little staff interaction with residents was observed. No attempt was made to provide any activities to a resident that walks around the home. Lunch was well organised and residents said they enjoyed the meal. One resident said, ‘the sponge was lovely, it melts in your mouth.’ The inspector sampled the meal, which was good. The meat was very tender and the sponge pudding was tasty and light. Menus were varied and nutritionally balanced. An inspector noted the manner in which a tray of food was left in front of a resident, which made it difficult for them to eat the food comfortably or balance the plate. This was pointed out to the manager at the time, who spoke to the member of staff concerned and corrected the situation. It is recommended that meals taken to residents on trays, out of the main dining area, are covered to retain heat and protect the meal before being served. Some residents had been identified as needing special diets, including soft food. However, one resident has been noted as needing a low sugar diet, despite there being no nutritional assessment or advice from a medical practitioner. Staff confirmed the arrangement was to suit the resident’s relative and that the resident insisted she be given sugar in drinks, as that was her preferred way. One care plan stated that the resident should be given soft ‘mashable’ food but they were being given dry toast. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 16 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 Relatives have not felt the need to make a complaint but the home should raise awareness of the complaints procedure. EVIDENCE: Nine relatives returned comment cards. All stated that they had not had to make a complaint but six also stated that they were not aware of the home’s complaints procedure. The procedure is displayed in the entrance. A previous additional visit identified that a serious allegation of abuse had not been reported to Adult Protection or the CSCI. After an initial poor response from the provider, a thorough investigation was carried out and action was taken to address shortfalls. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 17 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, 20, 21, 24, 25, 26 The improvements in the garden are positive because residents can now spend time outside in pleasant surroundings. The home is clean and maintenance work has been carried out but an audit system needs to be introduced to ensure environmental problems are identified. EVIDENCE: The enclosed garden at the side of the home has been tidied up, and plants and furniture have been purchased. This is a good improvement and residents will benefit from the changes. The home was clean and tidy. Communal areas consist of one large lounge, one quiet lounge (designated smoking area) and dining room. Lounges and the dining room are spacious and comfortable. Two relatives survey cards stated the home is always clean and tidy. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 18 Previous inspections have highlighted significant numbers of maintenance issues; this inspection also highlighted several maintenance problems. The provider had addressed most of the issues previously raised although some were not carried out promptly. The manager stated that she is planning on introducing an environmental and health and safety audit. This process should pick up the following areas that need attention. • • • • • • • • Hot water outlets. The temperature of hot water from two baths was very hot; the thermometer gauge exceeded 50 C The passenger lift does not always stop on 2nd floor Malodour in three rooms Inadequate lighting in the small lounge Towel dispensers empty, correct towels not available. Window panes were cracked in two rooms One bedroom window only had one curtain, other curtains were not fastened to the rails properly The bolt on the dining room door, which is also a fire exit, is very stiff and difficult to operate Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 19 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 Satisfactory information is not obtained prior to employment, which could result in unsuitable persons working at the home. Staff are encouraged to attend training and more opportunities are being offered. Individual training needs should be identified because some staff are not performing their duties satisfactorily. The home has been operating below the minimum staffing numbers therefore the quality of care and resident’s safety has been compromised. EVIDENCE: Several inspection visits have identified that the recruitment practice was poor. Only the manager has started working at the home since the last visit. These recruitment records were looked at. A CV was provided and this confirmed that the manager was a qualified nurse and had the relevant management qualifications but the employment history only had details of the year employment commended and ceased, therefore it was not possible to identify any gaps. A Criminal Records check was not available. A record of the interview was made. The manager had completed an audit that identified which staff records were missing and has requested them from staff. Staff said that they have received more training recently. External trainers have facilitated the courses and a record of attendance was available. Four staff have completed NVQ level 2. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 20 Staff training records were looked at. Each staff had an individual training record but it was very difficult to establish what training was still required. It was established that some staff had not completed some mandatory training, this included first aid, food hygiene and moving and handling. A training plan was not available. The manager had issued a notice to staff that stated training was compulsory. Previous inspections have identified that additional training was required for some senior staff to ensure they had the knowledge and skills to carry out their duties. This training has not been carried out and it was evident again at this inspection that staff competence was still an issue. The pre-inspection questionnaire stated that all residents had low care needs. The manager stated that some residents had high care needs, some medium and some low. Observation of residents during the inspection confirmed that all residents did not have low care needs. The last additional visit identified that the registered provider had reduced the staffing levels without consultation, and by departing from the agreed staffing levels we did not feel this demonstrated integrity. The staffing levels have since been re-introduced, although there was evidence that the home had operated below the minimum level on three occasions within the last two weeks. A new rota system had just been introduced and staff were pleased with how this would improve their work pattern. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 21 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, 33, 35, 36, 37, 38 The manager has had a positive effect on the staff, and has identified some areas where the home must improve. Financial records for residents’ monies are good. Some important information is not recorded and other information is inaccurate. This does not enable residents’ health and welfare or events in the home to be properly monitored. The quality monitoring systems are ineffective, therefore the home does not make effective progress. EVIDENCE: The manager had only been in post for three weeks. Staff said she had already introduced some positive changes, and they felt she was providing good leadership and guidance. She had spent time talking to staff and observing care practices, this has included bed making and inspecting bedrooms. Formal supervision had commenced and although not all staff had attended a supervision session there has been good progress in this area. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 22 The manager talked about various areas that she had identified for development and acknowledged that a lot of work has to be done before the home would meet the national minimum standards. The manager’s job description was from a large organisation and some of the responsibilities did not apply. For example it referred to an operation manager but Adel Grange does not have one, therefore it was not appropriate. On the second day of the inspection, the manager produced another job description, although this did not state that it was for Adel Grange. Daily records and incident reports contained conflicting information. For example, one record stated that there was no injury but an account of the same incident stated that the resident had banged their head. Different dates had also been recorded for the same incident. The pre-inspection questionnaire stated that policies and procedures were available. The inspector requested to see six of the policies. Whistle blowing, staff grievance and disciplinary, death of a resident, emergency and crisis, emergency procedure and nutrition. Three were not available and two required additional information. The home’s whistle blowing policy does not give staff information about reporting concerns to external agencies, this information should be added to the policy. The staff grievance and disciplinary policy does not contain information about the relevant processes. A letter is sent to the provider after each additional visit. The provider is then required to send an action plan detailing what action will be taken to address the points raised at the inspection. Several of the action plans have not been received on time. The registered provider has carried out monthly audits although these do not successfully pick up issues until after inspectors have raised them. The audits should be used to monitor the quality of the home. Reports are written for the commission and not for the purpose intended. Relatives or appointees usually take responsibility for residents’ finances. The home only held money for two residents. Financial records were looked at and transactions were recorded and receipts obtained. This was good practice. Staff have raised money for a residents’ fund. Financial records were not available although the manager agreed with the staff team to set up a formal system. Safe working practice risk assessments were looked at. Some were very general and did not contain the correct guidance. The manager had started reviewing these and adding additional assessments. There was still a lot of work to do in this area. COSHH data was also looked at. Relevant data was not Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 23 available for most of the cleaning substances were being used in the home, hence, if an incident occurred the home would not know what action to take. Staff do not carry out moving and handling safely. Staff confirmed that they required lifting belts and slide sheets. However, on two occasions these had not been used because the slide sheets were ‘missing’. These were later found in the cupboard in the dining room. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 24 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 1 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 X X 3 1 2 STAFFING Standard No Score 27 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 2 1 2 Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4 Requirement The registered person must ensure the statement of purpose accurately reflects the facilities and services that are provided at the home. The registered provider must make sure residents’ needs are accurately assessed before admission. The registered person must ensure that the care plans encompass all the assessed needs of the resident and demonstrate how those needs are met, review resident plans monthly and involve the resident and or their relative/representative. (Timescale of 30/09/05, 15/12/05, 31/01/06 & 31/03/06 not met) The registered person must ensure staff are aware of the contents of the care plans. Risk assessments must be fully completed and contain sufficient information so that staff know the action they need to take to DS0000001405.V292120.R01.S.doc Timescale for action 31/07/06 2 OP3 14 31/07/06 3 OP7 15 31/07/06 4 OP7 13 31/07/06 Adel Grange Version 5.1 Page 26 safeguard the resident. (Timescale of 15/12/05 & 31/01/06 not met) 5 OP8 12 The registered person must 31/07/06 ensure that the home is conducted so as to make proper provision for the health and welfare of residents- this relates to staff appropriately managing challenging or aggressive behaviour, monitoring bruising and injuries, and ensuring residents have sufficient fluids, are regularly toileted if support is required and have access to dental care. The requirement relating to challenging and aggressive behaviour has not been met as follows (Timescale of 30/09/05, 15/12/05 & 31/01/06 31/03/06 not met). The registered provider must ensure medication is administered appropriately The registered person must ensure the care home is conducted in a manner, which respects the dignity of residents. The registered person must ensure regular activities are provided, and these must be varied and suit residents interests, preferences and capacities. This must include social, cultural and religious needs The registered provider must ensure residents dietary needs are met. The registered provider must ensure the care home is kept in a good state of repair. Maintenance issues highlighted in the main body of the report must be addressed. DS0000001405.V292120.R01.S.doc 6 7 OP9 OP10 13 12 31/07/06 30/06/06 8 OP12 16 31/07/06 9 10 OP15 OP19 16 23 30/06/06 31/07/06 Adel Grange Version 5.1 Page 27 11 OP25 23 The registered provider must ensure hot water outlets, which can be accessed by residents, have thermostatically controlled valves. The registered provider must ensure the small lounge has adequate lighting. The registered person must ensure the deputy and seniors receive appropriate training that will equip them with the skills to carry out the work they are to perform (Timescale of 31/03/06 not met) The registered provider must ensure staff levels meet the minimum level agreed with the CSCI (Timescale of 31/03/06 not met). 31/07/06 12 OP27 18 31/07/06 13 OP27 18 30/06/06 14 OP29 19 The registered person must 31/07/06 provide and implement a robust recruitment procedure and must ensure that all information detailed in schedule 2 is obtained before new staff start work. (Timescale of 28/02/06 & 31/03/06 not met) The registered person must review the recruitment process for staff who have been reemployed at the home. Any conflicting information must be explored and appropriate action taken. (Timescale of 28/02/06 and 31/03/06 not met) 15 OP30 18 16 OP33 24 The registered person must provide a foundation and ongoing training programme for staff that meets the NTO specifications. (Timescale of 28/02/06 31/03/06 not met) The registered provider must DS0000001405.V292120.R01.S.doc 31/07/06 31/07/06 Page 28 Adel Grange Version 5.1 17 *RQN 26 18 OP36 19 19 OP37 17 20 OP38 13 introduce an effective selfmonitoring system. Monthly visits must be conducted in a way that enables the registered provider to accurately form an opinion of the standard of care provided. The registered person must implement a programme of formal supervision for care staff at least six times a year. (Timescale of 28/02/06 not met) The registered person must ensure accurate records are maintained. These should also be dated and signed. This relates specifically to daily records and information sent to the CSCI. (Timescale of 28/02/06 and 31/03/06 which relates to daily records in the home was not met) The registered provider must ensure safe working practice risk assessments are available. 31/07/06 31/07/06 30/06/06 31/08/06 21 OP38 13 Relevant data relating to hazardous substances (COSHH) must also be available. The registered provider must 31/07/06 provide a safe system for moving and handling residents. 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 OP15 OP16 Good Practice Recommendations The registered provider should make sure meals taken to residents out of the main dining room are covered to retain heat. The registered person should make sure residents and DS0000001405.V292120.R01.S.doc Version 5.1 Page 29 Adel Grange 3 4 5 6 OP28 OP35 OP36 OP37 their relatives are aware of the home’s complaints procedure The registered person should ensure a minimum ratio of 50 trained members of care staff is achieved. The registered provider should ensure records are maintained for the home’s residents’ fund. The registered person should look at staff development during supervision. Performance issues should be dealt with on a formal basis. The registered person should ensure policies and procedures contain the necessary information. This relates to the procedures identified in the main body of the report. Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Adel Grange DS0000001405.V292120.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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