Inspection on 28/05/08 for Alder Grange

This inspection was carried out on 28th May 2008.

CSCI found this care home to be providing an Good service.

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

Alder Grange 06/06/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Alder Grange 51 Adamthwaite Drive Blythe Bridge Stoke On Trent Staffordshire ST11 9HL Lead Inspector Pam Grace Unannounced Inspection 28th May 2008 10:15 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 Alder Grange DS0000069638.V365100.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. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alder Grange Address 51 Adamthwaite Drive Blythe Bridge Stoke On Trent Staffordshire ST11 9HL 01782 393 581 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) sally_appleton@yahoo.co.uk Eungella Care Ltd Anna Marie Carter Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care and accommodation (without nursing) for service users of both sexes whose primary care needs on admission to the homecare within the following categories: Old age not falling within any other category (OP) 15. The maximum number of service users to be accommodated is 15. 2. Date of last inspection 6th June 2007 Brief Description of the Service: Alder Grange is an extended Victorian Villa, which offers residential care accommodation for 15 older ladies or gentlemen. Access to the upper floor is assisted by a stair lift. Within half a mile of the service there are shops, a bank, a public house, and bus stops, whilst the railway station lies two thirds of a mile away. The home is under new ownership by Eungella Care Ltd. The Registered Care Manager is Ms Anna Carter. The home has a philosophy of a `Home for Life’. Alder Grange has recently become a ‘No Smoking’ Home. The fee chargeable for the service at Alder Grange is from £377.00 - £420.00 per week. The fee information included in this report applied at the time of inspection the reader may wish to obtain more up to date information from the care service. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars, this means that the people who use this service experience good quality outcomes. This key unannounced inspection was undertaken over approximately 9 hours by one inspector. The key National Minimum Standards for Older People were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff and people who use the service. A tour of the environment was also undertaken. The Registered Care Manager Ms Anna Carter and the Provider Ms Sally Haysom assisted the inspector during the inspection. The inspection had been planned with information gathered from the Commission for Social Care Inspection (CSCI) database and the Annual Quality Assurance Assessment (AQAA) document that had been completed by the Provider. Eight “Have Your Say” surveys were received from people who use the service, they were generally positive. Verbal comments received during the inspection visit were also positive, and included; “ the chairs are nice and comfy”, “I’m happy with my room, I’ve been able to put up some pictures and things”, “I always get my medication on time”. People spoken with were very positive about the care they were receiving. We observed people who were unable to communicate. Our observations showed that these people were well cared for, and were happy in their surroundings. There had been two complaints received by the Commission for Social Care Inspection (CSCI) since the previous inspection, both complaints were not upheld, and were dealt with in a timely and efficient manner by the Provider. No complaints had been received by the home. At the end of the inspection, feedback was given to the Registered Care Manager and the Provider. The home has a philosophy of a `Home for Life’. We did not make any requirements but made five recommendations made as a result of this inspection. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Staff records showed that appropriate recruitment checks on staff had been made. A deputy manager is now in post, assisting the care manager in the running of the service, and taking responsibility for the co-ordination of daily activities. Individual staff training records had been implemented. Training provision for staff continues to improve. Staff had attended numerous courses in the past year. There is evidence that training needs are monitored and courses planned accordingly. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 7 The home’s care plan format has been uniformly adopted for all people who use the service. These are now comprehensive and clear, making them easier to read and understand. Care plans are regularly reviewed. General, environmental and individual risk assessments have been completed, in liaison with an external agency/advisor. 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. Alder Grange DS0000069638.V365100.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 Alder Grange DS0000069638.V365100.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): 1,2,3 and 6 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. EVIDENCE: The Annual Quality Assurance Assessment document (AQAA), which was completed by the care manager, told us: “We have a robust admissions/assessment procedure in place. Any prospective service users are assessed by our registered manager/deputy manager prior to admission and prospective service users are encouraged to visit Alder Grange and stay with us for a short period in order to allow them to get a “feel” for the home. We are always available to speak to prospective service users/significant others to discuss any information that they may wish to Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 10 discuss. We have re-devised the literature in relation to Alder Grange, and this is openly on display in the entrance hall”. We were given copies of the Statement of Purpose and Service User Guide to look at. We saw that the Service User Guide is in the process of being reviewed, and there is a `Welcome Pack’ about to be implemented. Documents were being reviewed to provide people with up to date information to help them decide if the service will be suitable for them. We requested that copies of the reviewed documents are forwarded to the Commission for Social Care Inspection (CSCI). Surveys received from people who use the service said that they had received enough information about the home. We looked at four care plans. These showed that a full assessment of needs had been undertaken for those individuals on admission. These assessments gave good information about the person’s needs across all activities of daily living including; preferred bathing routines, food preferences, cognitive awareness, risk assessment including falls and moving and handling. People spoken with confirmed that they had received appropriate information prior to admission, which had included the Statement of Purpose. That they had been able to visit the home, and spend time talking with people who use the service to help them decide if the service would be suitable for them. People also confirmed that they had been provided with a contract/terms and conditions. Intermediate care is not provided in this home. Alder Grange DS0000069638.V365100.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 and 10 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. Medication storage needs further improvement to ensure that they are safe. EVIDENCE: The Annual Quality Assurance Assessment document (AQAA), which was completed by the care manager, confirmed the following: “We actively promote service users/significant other involvement in the review of care planning and delivery. We promote open communications between all, to ensure that all health and personal care needs are met. We have considerably strengthened our medication policy and procedures. We have invested in further training for all staff in relation to medication”. We examined four care plans. We spoke with staff, people who use the service, and their visiting relatives. Staff spoken with could tell us exactly how each person is individually cared for, what these staff told us reflected what was Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 12 written in individuals care plans. People we spoke to told us they had been involved in their care planning processes and their review. However, actions to be taken, in the event of terminal illness was not recorded within care plans seen. This was highlighted and discussed with the care manager at the time. People spoken with confirmed their satisfaction with staff, and said that they “speak to staff if I don’t feel too good”, “staff phone the doctor for me if I want them to”. “I usually feel well, but if I don’t, I’ll tell someone”. “I always get my medication on time”. Surveys received confirmed that people do receive the medical support they need. We undertook a spot check of the home’s medication administration system, which revealed that medication is appropriately administered. However, the steel cupboard, in which is stored controlled medication was fixed to the inside of the medicine cupboard door, making it easy to remove. It is recommended that it should be moved to the wall, and securely fastened with appropriate fixings. The care manager and staff spoken with confirmed that medication training for staff is via a local pharmacy, and is well documented. Each member of staff responsible for giving medication would have completed that training, prior to being given the responsibility for administration. The care manager is responsible for the daily monitoring of medication records. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 13 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 and 15 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their life style and are supported to develop their life skills. However, social, educational, cultural and recreational activities should meet individual’s expectations. Forums available for people who use the service to have their say in the dayto-day running of the service are lacking. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, which was completed by the care manager, confirmed the following: “Our deputy manager now assumes overall responsibility for activities within Alder Grange. We plan a monthly outing, to which all service users are able to attend if they should wish. We have a notice board upon which all the forthcoming activities are displayed, and records are kept regarding the activities undertaken and who has been involved in them. We try and undertake a range of different activities, sometimes in groups and sometimes on a one to one basis. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 14 We have employed a new Chef, and we believe that the quality, presentation and choice of food has improved immensely over the last 12 months. We are keen to encourage service users to try new meals, but we stress that they are always able to choose an alternative to what is on the menu should they wish to. We will continue to develop our activities programme, and are currently in the process of developing a safe and secure sensory garden for service users which we feel many of them will obtain a great deal of pleasure from this.” The deputy manager confirmed that she has the responsibility for coordinating activities and trips out for individuals. People and staff spoken with confirmed that the mobile library still calls regularly. People who use the service said they can “go out walking”, “go out shopping”, “play dominoes”, “board games”, skittles, watch films, reminiscence discussions, they also said “we had a clothing sale, and bought nightdresses”. The notice boards displayed forthcoming events, e.g. trips, outings e.g. Chester Zoo. A barbeque had been organised to celebrate a person’s 90th Birthday. People spoken with, also said that “they only have activities, if enough staff are on duty, and if staff are not too busy”. There was no activity in progress during the inspection visit, and the notice board did not show what activities were on that day. There was little evidence to support the activities being undertaken each day. Surveys received confirmed that people `usually can’ take part in activities provided. We sampled the food on offer for lunch, which was roast pork, roast potatoes and mixed vegetables, followed by rhubarb crumble and custard. People were offered a choice of main course and sweet. We asked people for feedback during the meal, and feedback was then given to the care manager. People spoken with confirmed that the meal was tasty, and well presented, however they felt that the meat was `stringy’, and that the vegetables were a bit too hard. “The crumble had gone hard like rock”. Two people said that they usually liked the meals on offer. However, they did not know who to feed back to about the meals, as there is no forum for this. Surveys received confirmed that people usually liked the meals. Four weekly rotational and seasonal menus were in place. However, there should always be an alternative choice of meals on offer to people each day. This was highlighted and discussed with the care manager at the time. Alternative choices are offered to people, but this had not been written into the menu. These will be added to the existing menu. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 15 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 and 18 – 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 are able to express their concerns, and have access to a robust, effective complaints procedure. People are protected from abuse, and have their rights protected. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, completed by the care manager, confirmed the following: “We promote an open and honest approach to incident reporting/complaints, as we do not view these negatively. We are keen to learn from any such issues and view any concerns constructively and always attempt to deal with concerns promptly and pro-actively. We have reviewed staff recruitment files and feel that we have a robust recruitment policy/procedure in place.” We saw that the complaints procedure was displayed in the main entrance to the home. Larger print versions would be made available if required. The care manager confirmed that people who use the service and or their representatives are provided with a copy of the home’s complaints procedure during the admission process, this is to be included in the home’s new Welcome Pack. People spoken with during the inspection visit confirmed that they knew who to complain to. They said that their grumbles are listened to and acted upon by Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 16 staff. We saw evidence of comments made by relatives, which were very positive about the care their relatives had received, and also viewed the `grumbles’ book, which evidenced that people who complain are listened to, and complaints are acted upon straight away. Surveys received confirmed that people know who to speak to if they’re not happy, and know who to complain to. The home had received no complaints since the previous inspection. We had received two anonymous complaints about this service, both of which had been appropriately dealt with, and had not been upheld. We discussed these complaints during the inspection process. There had been no Protection of Vulnerable Adults (POVA)-Safeguarding referrals made to Social Services since the previous inspection. The staff training programme included POVA/Safeguarding training for staff, dates for this were in the process of being agreed. Three staff recruitment files were examined. They contained all the appropriate security and police checks, and evidenced a good standard of procedures from an administrative point of view. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 - Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: This outcome area was rated as `poor’ at the previous inspection. Since then the provider has made concerted efforts to redecorate and refurbish areas within the home, on a rolling programme basis. The Annual Quality Assurance Assessment (AQAA) document, completed by the care manager, confirmed that all health and safety checks on equipment and fire systems had been undertaken, and confirmed the following: Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 18 “We have fully involved service users with regard to individual room redecoration, and service users have been encouraged to choose wallpapers, paint, bedding etc to their own personal preference. We have invested very heavily in the general re-decoration and modernisation of Alder Grange since we took over. Both communal and individual bedroom areas have been targeted, and we have attempted to prioritise the works that need undertaking. As well as cosmetic work (re-decoration, new furniture, carpets), we have invested heavily in areas such as improving the plumbing system, fire alarm detection system, and roof repairs. We have commissioned a joiner to provide us with robust stair gates as the previous owner utilised `safety gates’ that we felt were inappropriate in a residential home.” We undertook a tour of the environment. The home provides a clean environment throughout. Accommodation is personalised to suit individuals. Communal areas are comfortable and homely. Bathrooms and toilets are conveniently sited around the home. Some of these areas were highlighted as requiring redecoration and or refurbishment. We looked at the kitchen, which was in need of refurbishment and updating, but is very clean and tidy. An urn used by staff to make hot drinks for residents was inappropriately placed in the dining room. This was highlighted and discussed with the care manager, and the provider. This was re-sited straight away, for the safety of people who use the service. Kitchen records seen confirmed that hot food temperatures are taken daily and recorded, this is as well as fridge and freezer temperatures. The freezer in the food preparation room had gone rusty, and the seal is no longer efficient. This needs replacing, and was highlighted to the care manager at the time. People spoken with during the inspection visit expressed their satisfaction with the general environment, their room, and the equipment provided within the home. One person showed us their room, and said that “they were pleased with it” and “the staff work hard to keep the place clean”. Surveys received confirmed that the home is always fresh and clean. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained and skilled. However, they should be in sufficient numbers to support the people who use the service. EVIDENCE: People who use the service had previously highlighted the need for more activities, which were dependent upon better staffing levels. Surveys received confirmed that staff listen and act on what people say, and staff are available when you need them. During the inspection visit we discussed staffing levels with individual people, and there were no shortfalls highlighted. People were generally satisfied with the service received. However, activities are not provided for within the current level of staffing. There are two care staff on duty at any one time, throughout the day and night for 14 people currently residing at the home. The care manager does not perform care duties, and is therefore not `hands on’. People had said that activities did not run if there was not enough staff on duty. It is a recommendation of this report that staffing levels are increased to include dedicated hours for activities each day. Staffing levels should be kept under review as per the needs of the people who use the service. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 20 The Annual Quality Assurance Assessment (AQAA) document, completed by the care manager, confirmed the following: “We feel we have improved training opportunities for all staff, and our registered manager has developed the training matrix further as well as now keeping individual training records for staff. We continue to encourage staff with their NVQ programmes and one of the directors is also undertaking the A1 Assessors award. Risk assessment training provided for key staff. Fire training provided with another 6 monthly update planned. We are also awaiting further infection control training (requested, just awaiting dates) for staff who have yet to undertake this. We now have a deputy manager who is able to support our registered manager with the day to day running of the business”. Staff spoken with confirmed that they had received updates in regard to mandatory training, including moving and handling, health and safety, Fire and Medication. However, they were not aware of the need for staff supervision, which has not yet been fully implemented. Three staff recruitment files were examined. They contained all the appropriate security/police checks, and evidenced a good standard of procedures from an administrative point of view. The care manager has implemented individual training records for all staff since the previous inspection. The staff training matrix confirmed the training that staff had received. The provider confirmed that nominated staff had undertaken training in risk assessment. This was in liaison with an outside agency come advisor. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. The home should further develop its quality assurance system to make sure that services are provided in the best interests of those who use them. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, which was completed by the care manager, was returned to the Commission for Social Care Inspection on time, and was completed to an adequate standard. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 22 The Annual Quality Assurance Assessment (AQAA) completed by the care manager confirmed the following: “Over the past 12 months we have made significant improvements to the management and administration of Alder Grange. Our manager is now registered and undertaking her RMA, and she also has the support of a deputy manager to assist her in the day to day running of the business. Both undertake a very pro-active role within the company, supporting the management team and all staff at Alder Grange. Within our belief system, it is not negotiable that the home is run in any ones interests apart from the service users themselves. We have reviewed all policies and procedures and have also strengthened the arrangements for residents’ personal money”. Information pertaining to the home was on display in the entrance hallway. New brochures and a Welcome Pack had been printed, which reflected the new management and staffing structure of the home. The home has been under new ownership for the past 12 months. New paperwork is now in place, and is used for all assessments and Care plans. These were comprehensive and showed attention to detail. Care plans seen evidenced involvement of other health professionals, i.e. dietician, General Practitioner. Individual staff training records are now in place for all staff, as well as a comprehensive training matrix. The care manager confirmed that she had completed the Trainer’s course in Moving and Handling, and will now be able to train and update care staff at the home. She is also in the process of undertaking the Registered Manager’s Award, and has undertaken risk assessment training since the previous inspection. Medication administration procedures were checked during this inspection. Administration was carried out in a safe and professional manner. The Medical administration recording sheets (MAR) were completed appropriately and all refusals were documented and explained. Our ‘Have Your Say surveys’ received from people who use the service confirmed that they were ‘satisfied’ with the services that they received. However people spoken with said they didn’t know how to comment and give their views, as there is no forum for this. This links in with the need to further develop the quality assurance system for the service. We discussed the need for regular documented resident and staff meetings, with feedback of outcomes from any surveys undertaken by the provider. The score of 2 for this standard reflects the work still needed to meet this quality assurance standard. Two anonymous complaints sent to us since the previous inspection, both had been appropriately responded to, and not upheld. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 23 Numerous compliments have been recorded in the complaints and compliments book. These were discussed with the provider in light of the need to provide evidence of quality assurance systems. The home has a robust recruitment procedure. Protection of Vulnerable Adults and Criminal Records Bureau checks are carried out on all potential staff members. There had been no Safeguarding referrals made since the previous inspection. We undertook a spot check in regard to people’s finances. There were robust systems in place to ensure that finances are safeguarded. The provider had begun an ongoing redecoration and improvement at the home, since the previous inspection, this was also highlighted in the Annual Quality Assurance Assessment. Those improvements were evident during this inspection visit. The provider stated in the AQAA that the routine checks and maintenance of equipment had taken place for example; portable and electrical equipment, lifts and hoists, fire detection, emergency call, heating system and gas appliances. Individual staff training records had been implemented since the previous inspection, and staff interviewed confirmed that they had received mandatory and update training. Records seen evidenced regular staff meetings. Regular meetings for people who use the service are needed, and are to be introduced by the deputy manager, as part of her role of activities organiser. The providers have recently introduced regular surgeries for people who use the service and their relatives, to enable and promote discussion, and to answer any queries or concerns. This will also contribute towards the quality assurance evidence for the service. Staffing levels had been maintained, however, extra staff hours are needed to enable dedicated time for activities. Staffing levels should be kept under review according to people’s level of need. Alder Grange DS0000069638.V365100.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 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 3 3 Alder Grange DS0000069638.V365100.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. 1. Refer to Standard OP7 Good Practice Recommendations Care plans should state the arrangements made for an individual in the event of terminal illness this is to make sure that the staff will know what to do for people at this time. The steel cupboard used for storing controlled medication should be moved to the wall, and securely fastened with appropriate fixings, to ensure it cannot easily be removed to increase safety and ensure that there is no risk to people who use the service. Staffing levels should be kept under review according to the needs of people who use the service. The kitchen door should be kept closed, as this is a fire door. To increase safety for people living at the service we recommended that after consultation with the Fire authority, magnetic catches, linked to the fire safety system be fitted to those doors that need to be kept open for people’s access. DS0000069638.V365100.R01.S.doc Version 5.2 Page 26 2. OP9 3. 7. OP27 OP38 Alder Grange 8. OP38 The urn used for hot drinks should be safely sited to prevent injury to people who use the service. Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Alder Grange DS0000069638.V365100.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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