Inspection on 05/11/07 for Adel Grange

This inspection was carried out on 5th November 2007.

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

Adel Grange 14/12/06

Adel Grange 23/05/06

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 5th November 2007 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.V351539.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 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.V351539.R01.S.doc Version 5.2 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 2611288 0113 2674398 Parkfield Healthcare Ltd Ms Hilary Preston Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2006 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. The fees charged by the home range between £371.88 and £460 per week. This information was provided on 5 November 2007, during the inspection. The registered manager said basic hairdressing and chiropody charges are included in the fees. Information about the home including a Statement of Purpose, Service User Guide and previous inspection reports are available at the home. Up to date information about fees can be obtained directly from the home. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out a site visit and was at the home between 9.30am and 5.00pm. During the inspection process all of the key standards were looked at to try and find out what it was like to live at the home. The last key inspection was carried out in December 2006. An annual quality assurance assessment (AQAA) was completed by the home and this information was used as part of the inspection. Survey forms were sent out to people living at the home, their relatives and health care professionals. Sixteen surveys were returned. Six from people who live at the home; relatives supported three to complete the surveys and care staff helped the other three; nine surveys were from relatives and one was from a healthcare professional. Comments from the surveys have been included in the report. Two hours were spent observing the care being given to a small group of people. The care of five people was looked at in depth, which included how staff interact with people at the home. Comparisons with the observations were made with the home’s records and the knowledge of the care staff. Feedback was given to the registered manager and proprietor at the end of the visit. During the visit the inspector looked around the home, spoke to people who live at the home, a hairdresser, four staff, and the registered manager. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: During the site visit, people at the home looked relaxed and comfortable. Two people talked about living at the home. They said ‘it suits me just fine’, ‘staff come and talk to me and bring me drinks’, ‘I’ve got some good friends here’, ‘there are some good ones’ (this was a reference to staff) and ‘I’m satisfied’. The general appearance of people who live at the home was good, they were dressed appropriately and attention had obviously been given to their personal care. For example, people’s hair had been brushed and their glasses, shoes and clothing were clean. During the observation period, everything was done at a relaxed pace. Staff treated people with warmth and respect, and they were kind and courteous. People were asked discreetly about personal care. Staff were vigilant and as soon as people required assistance they attended. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 6 Several people who live at the home interacted well and chattered with other people who live at the home. This gave some quieter people good opportunities to engage in conversation. Surveys from relatives were very positive and it was evident they were happy with the care provided. The following are a sample of typical responses and comments: • • • • • • • Drinks and biscuits come around regularly It’s a well run home The atmosphere is peaceful and relaxed I think they do an excellent job at Adel Grange My relatives health has improved, she is much more content and less anxious The standard of care has been excellent It’s a friendly environment What has improved since the last inspection? What they could do better: Hot water was tested in several bedrooms and bathrooms. Most sinks and baths did not have hot water; one bedroom sink had very hot water but only a very slow water flow. The manager had records that confirmed the water Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 7 temperature at ever outlet had been tested weekly and the water temperatures were ok, although the temperature checks were always completed by night staff. Staff said that sometimes there is a problem with hot water. The manager said she thought the problem could be because the hairdresser was at the home for the day and could have used a lot of hot water. The proprietor said he thought the temperature valves might need adjusting. They agreed the system needed monitoring and an additional water system might be required. One requirement and two recommendations were identified at this inspection and are at the end of this report. 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. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 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.V351539.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 does not apply) People who use the service experience good quality outcomes in this area. People’s needs are properly assessed before they move into the home so everyone can be sure that the person is moving into the right home and their needs can be met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: In the AQAA the manager said, ‘we provide all prospective people with a brochure and whatever information about the home they need. Families and people who are thinking of moving into the home are invited to come to the home and see for themselves what we provide. An assessment of needs is carried out to ensure we are able to meet needs. Families are asked to complete a My Life booklet on behalf of the person to give staff some background information.’ Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 10 During the site visit, two sets of admission records were looked at. Each person had assessments that identified the type of support they required. The manager and deputy co-ordinate any admissions and complete the preadmission assessments. The manager said they always visit the person before they offer a placement at the home. People spoken to during the inspection said they could not recall whether they had been happy with the admission process when they moved in. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. A good care planning system is in place to make sure individual needs are met. People who live at the home are treated with dignity and respect. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Six surveys were received from people who live at the home; all received help to complete the forms. They said: • • • • • They usually receive the care and support they need Staff listen and act on what they say Staff are usually available when they need them They always receive the medical support they need They like the meals DS0000001405.V351539.R01.S.doc Version 5.2 Page 12 Adel Grange One healthcare survey was returned. This said: • • • • The care service usually seeks advice and acts upon it The care service usually respects the individual’s privacy and dignity Staff usually have the right skills and experience Provides a caring environment Two hours were spent observing the care being given to a small group of people. The care of five people was looked at in depth, which included how staff interact with people at the home. During the observation, everything was done at a relaxed pace. Staff treated people with warmth and respect and they were kind and courteous. People were asked discreetly about personal care. Staff were vigilant, and as soon as people required assistance they attended. For the majority of time the five people showed positive mood states and obvious signs of well-being. Several people who live at the home interacted well and chattered with other people who live at the home. This gave some quieter people good opportunities to engage in conversation. People who were quieter and didn’t ask for assistance had less staff interaction. The manager has a good policy that a member of staff must remain in the lounge at all times. Staff said this worked well and made sure people got attention straight away. Although during the observation it was noted that on some occasions staff were watching people, rather than interacting. The general appearance of people who live at the home was good, they were dressed appropriately and attention had obviously been given to their personal care. For example, people’s hair had been brushed and their glasses, shoes and clothing were clean. A regular visitor said, ‘you can tell everyone is well looked after’, ‘everyone is happy’, ‘staff are kind and lovely’, ‘it’s fab’. In the AQAA the manager said, ‘care plans reflect people’s individual needs. People who live at the home are happy and animated, they look clean and tidy and well cared for. Relationships with GPs and other healthcare professionals are good and they appear to trust us and accept that we are giving good, proactive care.’ Three care plans were looked at. These were well organised. Information in the care plans was good and gave sufficient information about potential risks and how individual needs should be met. There was evidence that guidance in the plans was followed. For example one plan stated the person must be weighed weekly and a weekly weight record was maintained. Life history booklets had also been completed. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 13 It was also evident people’s health and welfare was being properly monitored. Monthly reviews identified any changes in needs and any significant events. Falls or accidents were monitored and healthcare appointments were clearly recorded. Staff had signed the plans to confirm they had read them. Staff also said they were encouraged to read the care plans. A notice in the entrance of the home provided people with information about care planning. There had been two incidents recorded during the previous weekend that had raised concerns. It was noted that one person had been very aggressive towards staff. The manager said this was completely out of character, and she agreed to look into the incidents. The manager identified that she had to look at the person’s current state of health, the content of the record, talk to staff and if appropriate healthcare professionals, and complete a risk assessment and care plan. This is good practice and shows that different causes are considered. The home’s medication system is a Monitored Dosage System. Medication records were looked at and they had been completed correctly. The deputy manager confirmed that staff who administer medication must have completed medication training. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. People enjoy living at the home and feel well cared for. Staff work hard to make sure people receive varied lifestyles within the residential setting. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: During the site visit, people at the home looked relaxed and comfortable. Two people talked about living at the home. They said ‘it suits me just fine’, ‘staff come and talk to me and bring me drinks’, I’ve got some good friends here’, ‘there are some good ones’ (this was a reference to staff) and ‘I’m satisfied’. Surveys from relatives were very positive and it was evident people were happy with the care provided. The following are a sample of typical responses and comments: • Drinks and biscuits come around regularly • It’s a well run home • They provide stability and routine Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 15 • • • • • • • The atmosphere is peaceful and relaxed I think they do an excellent job at Adel Grange My relative’s health has improved, she is much more content and less anxious The standard of care has been excellent It’s a friendly environment All nine people surveyed said they were always kept up to date with important issues. Two surveys had additional comments about people at the home being clean and well dressed Under the ‘how do you think the home can improve’, relatives suggested the following: • Perhaps more activities • Two surveys made reference to the laundry. One said, ‘the laundry service is good but sometimes clothes are ruined.’ The other said, ‘sometimes there is confusion with clothes.’ In July 2007 the CSCI received a letter from a relative commending the home on the care they provided. They said, ‘our family has noticed a tremendous improvement in mum’s overall health; it is very reassuring to see how thoughtful staff make sure she always looks well groomed and ‘put together’. Adel Grange is a shining example of how well a residential home can be run.’ In the AQAA the manager said, ‘people are well cared for. They have a good quality of life. We try to organise the home around their wishes and needs and try to keep to their own preferred routines. We have no set pattern or timing to the day and each person who lives at the home has the freedom of choice as to when they get up, or go to bed, and how they spend their time.’ Daily records had good information about routines which included times for getting up and going to bed. These were varied. Over a two week period, one person had gone to bed between 8.00pm- 10.30pm, and they got up at different times. This is good practice and shows the home offers a flexible service. There was also good information about family contact and entertainment. Twice a week a person visits the home and does a motivation session with people. An entertainer visits every other Wednesday, and a person visits and does an art and craft session the alternate Wednesday. A volunteer takes people out for walks and shopping. Another volunteer was due to start, the home was waiting for a criminal records check. The manager has advertised for an activity organiser to work at the home because she had identified that this would help enhance the level of daily activity. Staff thought this would be beneficial because sometimes they said Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 16 they were very busy. This is good practice and demonstrates that management look at how they can continue to improve the quality of life for people living at the home. The AQAA also said, ‘we have visits from the local priest to give communion to the catholic people who live at the home, and the local Church of England vicar calls at times. We have forged a link with the Jubilee church in Leeds who visit to give a multi- denominational sevice and sing hymns with the people who live at the home.’ The manager talked about recent changes that had been made to the laundry service. She acknowledged there had been some problems, some items of clothing had been damaged and some had got mixed up. To address the problem, she had introduced a new system for taking and returning clothing to the laundry, and laundry staff were the only people who washed items of clothing. The manager said since the new system had been introduced, she had not received any concerns. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. The people who live at the home are safeguarded. Relatives are confident that they will be listened to and that appropriate action will be taken when necessary. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Surveys from people who live at the home said they know how to make a complaint. Relative surveys stated they know how to make a complaint about the care provided and the care service has responded appropriately if they have raised concerns. The complaints procedure was displayed near the entrance and this provided details of who to contact if people were unhappy with the service. In the AQAA the manager said, ‘our relative surveys reflect that they are happy with the service provided. Staff are aware of how to raise any concerns they may have, families are always shown the complaints procedure on admission.’ Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 18 Staff and management have attended adult protection training and were familiar with the adult protection procedures. Safeguarding procedures were displayed above the reception desk. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 People who use the service experience good quality outcomes in this area. People live in a nice, homely environment. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: A tour of the building was carried out. A selection of bedrooms, all communal areas and bathrooms were visited. The home was very clean and tidy and there were no odours. The home was bright and there were lots of additional items to create a homely feel. For example, there were vases of flowers, pictures and tablecloths. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 20 The entrance was welcoming and there was a lot of information to tell people what was happening in the home. Coffee and water were readily available. Bedrooms were personalised and some people had brought items when they moved in, which included pictures, ornaments and photographs. Several areas of the home had been decorated. The manager said there is not a fixed programme of decoration but rooms are decorated when they start to show signs of wear and tear. This system appeared to work satisfactorily. The ground floor bathroom was out of use because of refurbishment. The proprietor said it would be completed by the end of November. The carpet on the top floor had a big bleach mark on it and several other marks. The proprietor said he would replace this. Relative surveys had a couple of suggestions for how the home could improve. They suggested the following; • • A quicker response to repair the lift when it is out of order The water in the bedroom is not hot enough. The manager said there had been problems with the lift but it had recently been completely overhauled and was now running ok. The last inspection did not identify any problems with the heating and hot water system but previously there have been problems. During the observation period, it was noted that the lounge was very warm and some people were quite sleepy, and the dining room was cooler. The manager and staff said generally the heating was ok but because it is an old building, some days when there is a sudden change in the temperature outside, it takes a while to get the right temperature in the home. Hot water was tested in several bedrooms and bathrooms. Most sinks and baths did not have hot water, one bedroom sink had very hot water but only a very slow water flow. The manager had records that confirmed the water temperature at ever outlet had been tested weekly and the water temperatures were ok, although the temperature checks were always completed by night staff. Staff said that sometimes there is a problem with hot water. The manager said she thought there might be a problem because the hairdresser was at the home for the day and could have used a lot of hot water. The proprietor said he thought the temperature valves might need adjusting. They agreed the system needed monitoring and an additional water system might be required. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 21 Throughout the home there were supplies of wipes, hand wash, aprons and thermometers for testing the temperature of bath water. Surveys from people who live at the home said the home was always fresh and clean. In the AQAA the manager said, ‘The furniture and fittings of the home are geared up to care of elderly people and we provide such aids are as needed.’ Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. People who live in the home are supported by a caring and skilled staff team. Everyone receives good training opportunities, which equips them with the knowledge and skills to successfully perform their duties. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: In the AQAA, under the ‘what we do well section’, the manager said, ‘we have achieved a great deal of training, recruitment has been good , and we are attracting good quality staff. Support and supervision of staff is carried out regularly. We have balanced teams and staff are aware of their responsibilities.’ Surveys from relatives were very positive and it was evident people were happy with the staff and management team. • One survey said they have staff who go the extra mile • Seven surveys said staff always have the right skills and experience; two said usually Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 23 Two surveys mentioned staffing levels. One said, ‘sometimes I think they should have more staff because at times they seem under pressure.’ Another said, ‘there has been a recent increase in numbers, I’m not sure what time staff have now for 1 to 1 care.’ Staff and management were asked about staffing levels. The manager said staffing levels were satisfactory and she could bring in extra staff if she thought it necessary. She said they were trying to recruit an activity organiser to provide some additional time with people who live at the home. Staff also thought staffing levels were generally satisfactory although they said sometimes they were very busy. Recruitment records for two staff and one volunteer were looked at. All the relevant information was available. The manager said care staff have a week’s induction and during that time they are not included in the staffing numbers. In the first few months, they also complete the ‘Common Induction Standards’ with a training organisation. The two new staff had induction files that confirmed they had gone through important policies and procedures and completed a set of questions about good care practice. There was not an induction checklist for each staff member to confirm that they had gone through some important induction elements for example, layout of the building, location of fire exits. The manager agreed to introduce a checklist. A training matrix was looked at and this confirmed that staff had attended various training courses during the past few months. A training programme was displayed and showed that several courses were being provided over the next three months. All staff have completed or are completing NVQ awards. Nine out of eighteen care staff have completed NVQ level 2, and seven of these staff have started NVQ level 3. The other nine care staff are completing NVQ level 2. Both catering staff are completing NVQ level 2 in catering, and domestic staff are completing NVQ level 2 in housekeeping. This is good practice because it provides staff with the knowledge and value base to carry out their jobs properly. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 People who use the service experience excellent quality outcomes in this area. The home is very well managed. People who live and work at the home feel valued and involved and enjoy a friendly and relaxed atmosphere. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Four staff were asked the management of the home. Each staff member was very clear that the home had greatly improved over the last eighteen months and this was as a result of good management. The following are examples of typical comments; ‘the manager is really good’, ‘there is a better atmosphere’, Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 25 ‘the home is much better’, ‘we are more professional’, ‘the manager has done a lot of work’, ‘staff have learnt how to provide good care’, ‘we have more people saying we’ve done a good job’ and ‘people know we care’. In the AQAA, under the ‘what we do well section’, the manager said, ‘we have an appropriately trained manager with good organisational skills. Documentation is up to date and appropriate. The manager is a strong leader who is guiding staff to do their job correctly and take pride in their work.’ Personal allowance records were looked at. All financial transactions were recorded and receipts were obtained for any purchases made. Two people’s monies were counted and the amount corresponded with the amount on the balance sheet. The AQAA also said ‘monthly audits are carried out of all areas, health and safety, fire, catering, accidents, drug administration and storage. Care plans are reviewed as required or at least monthly.’ The registered manager and registered provider tell the CSCI about important events that happen at the home. Since the last inspection the CSCI have received regulation notifications and monthly reports about the conduct of the home. No concerns around safe working practices were seen on the day of the inspection. In the AQAA the manager said relevant policies and procedures were in place, and reviewed in July 2007. She also said equipment has been serviced or tested as recommended by the manufacturer or regulatory body. Portable electrical equipment was tested in August 2007, Hoisting equipment was serviced in May 2007 and emergency call equipment was tested in July 2007. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 26 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 X X 3 Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 27 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. Standard OP25 Regulation 23 Timescale for action There must be a sufficient supply 31/12/07 of hot water, at all times, to meet the needs of the people living at the home. Requirement 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 OP19 OP30 Good Practice Recommendations The carpet on the top floor landing should be replaced to make sure the flooring is of an acceptable standard. An induction checklist should be completed with new staff to make sure they cover all the important aspects of the home during the induction period. Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Extracts may not be used or reproduced without the express permission of CSCI Adel Grange DS0000001405.V351539.R01.S.doc Version 5.2 Page 29 - 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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