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Inspection on 15/08/07 for Autumn Grange Care Home

Also see our care home review for Autumn Grange Care Home for more information

This inspection was carried out on 15th August 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Complaints are documented, investigated and complainants are responded to, ensuring that their concerns are addressed. Over half of the staff have achieved their National Vocational Qualification to make sure they are trained to meet the needs of residents who need care Proper checks are done on all staff who come to work at the home to make sure they are suitable to work with vulnerable people. The manager is experienced and was praised highly by people who live in the home as being kind, helpful and approachable. The manager and provider are open to suggestions and ideas on improving the service. Residents` finances are securely held and properly recorded to make sure their interests are protected. The tests and servicing of equipment at the home is done at the intervals suggested and this ensures that residents and staff have their health and safety protected.

What has improved since the last inspection?

What the care home could do better:

The initial assessments could include more personal and social history with information about the cultural and religious needs of the residents to help the staff understand and support people better. Where a person is unable to take part in the creation or review of a care plan this could be recorded in the review. The care plans could be more detailed about the personal, social, cultural and religious needs of the people who live in the home to ensure that staff give people the care they need. The activities that people take part in could be recorded to show how a person spends their day. Plans could record what time people want to get up and go to bed to ensure that their wishes are respected.

CARE HOMES FOR OLDER PEOPLE Autumn Grange Care Home 19-29 Herbert Road Sherwood Rise Nottingham NG5 1BS Lead Inspector Susan Lewis Key Unannounced Inspection 15th August 2007 10:00 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 Autumn Grange Care Home DS0000002190.V341208.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. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Autumn Grange Care Home Address 19-29 Herbert Road Sherwood Rise Nottingham NG5 1BS 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) 0115 8417475 0115 9620061 Sherwood Rise Ltd Nora Gazeley Care Home 76 Category(ies) of Dementia - over 65 years of age (51), Old age, registration, with number not falling within any other category (25) of places Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Registered Manager must be full time and have full time supernumerary hours of work Three Senior Carers to be in charge, one on each unit (three in total) from 08:00-20:00 For 76 service users at least 7 (seven) care assistants must be provided from 08:00-20:00 That the identified bedroom to be only used for residents who by virtue of their needs are unable to use an ensuite facility. 23rd November 2006 Date of last inspection Brief Description of the Service: The fees for 2006/07 are £323.23. The most recent inspection report can be found in the entrance hall. The home is located in a quiet residential area of Nottingham (Sherwood Rise) with access to local amenities. The city centre of Nottingham is about 1 mile away and there is a direct bus route to and from the city centre with a bus stop about 300m metres from the care home. A park and ride service is available, about 500 metres from the care home. The home is split into three units, two of which provide up to fifty-one (51) places for people who may have a Dementia related illness (residential, non-nursing). The other unit provides personal care (residential care, non-nursing) for up to twenty-five (25) older people. There is a choice of lounges and combined dining room areas. The building is wheelchair accessible with adaptations and equipment appropriate to the needs of the service users. The garden area to the front of the premises has an enclosed safe garden to enable residents to access it safely. Parking is limited at the front of the building but there is more space available at the rear of the building itself as well on the road parking. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and took place over 8.5 hours, including lunchtime. The main method of inspection used was called ‘case tracking’ which involved selecting four residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Two people living at the home speak languages other than English and one person was “case tracked” to check that staff understood and provided for their cultural, religious and communication needs. Some of the people who live at this home have a limited ability to understand and communicate. Therefore some judgements in this report are from observation of staff and resident interactions Two members of staff and one set of relatives were spoken to as part of this inspection. In addition the views of five other residents who were not part of the “case tracking” were sought to form an opinion about the quality of the service. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. The registration document was checked as part of this inspection and the categories and conditions were viewed to ensure they were suitable and correct. These have been amended to reflect changes in the way the Commission uses conditions of registration. What the service does well: Complaints are documented, investigated and complainants are responded to, ensuring that their concerns are addressed. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 6 Over half of the staff have achieved their National Vocational Qualification to make sure they are trained to meet the needs of residents who need care Proper checks are done on all staff who come to work at the home to make sure they are suitable to work with vulnerable people. The manager is experienced and was praised highly by people who live in the home as being kind, helpful and approachable. The manager and provider are open to suggestions and ideas on improving the service. Residents’ finances are securely held and properly recorded to make sure their interests are protected. The tests and servicing of equipment at the home is done at the intervals suggested and this ensures that residents and staff have their health and safety protected. What has improved since the last inspection? Any areas of possible abuse are passed to social services to ensure they are aware of what is happening in the home. Improvements are being made in ensuring the people who live in the home have more of a say about how the home is run. Staff are better at supporting choice for the people who live in the home. Activities are slowly increasing for the people who live in the home to provide them with socially and culturally appropriate entertainment. Staff have good access to training and this is beginning to improve the quality of care within the home. Questionnaires have been sent out to ask relatives for their views about the home, and how things could improve for the people who live in the home. A newsletter is provided to all relatives and people who live in the home to keep them informed of changes and ask their opinion. Improvements in the décor and new furniture has been purchased in the last twelve months to ensure the service is safe and a pleasant environment for people to live in. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 7 Systems are being created to monitor the care that people who live in the home receive and ensure there is ongoing improvement. 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. Autumn Grange Care Home DS0000002190.V341208.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 Autumn Grange Care Home DS0000002190.V341208.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, 3 and 6 Quality in this outcome area is good. People are assessed before they are admitted to the home to make sure their identified needs can be met. People’s cultural needs are not always identified. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The person’s relative spoken with said that they had received all the information they needed to assist they loved one making the decision to move to the home including information on the fees and how to raise concerns. There were aware of where the most recent report was kept and had been encouraged to read it by the manager. From information provided prior to the inspection visit the manager reported that prospective residents are encouraged to spend time at the home before Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 10 making the decision to move in, this could include spending a day there or coming for a meal. People who live in the home spoken with said they thought that they had been offered this although those who had moved from hospital said that they had not had time to do it. There is a service user guide, although this is currently being rewritten and a statement of purpose, these documents are written in English, and no other formats are currently available which may make them inaccessible to people whose first language is not English. Four care plans were viewed and showed that all residents are assessed prior to moving to the home and are assured by the manager that the staff are able to meet the person’s needs. However the standard assessment does not provide detail about a person’s cultural, religious and diverse needs to ensure that staff are aware and can meet all a person’s needs. The staff who were spoken with said they although they did not have anything to do with admissions they understood what the process was and that mostly senior cares and management were involved in ensuring new residents were settled in and care plans were completed. Staff confirmed that the manager goes out to assess people where possible, and they are informed about new people verbally at handover. This ensures that new residents receive the correct support when they first move to the home. Intermediate care is not provided at the home and this standard is not applicable. Autumn Grange Care Home DS0000002190.V341208.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. Residents’ health and personal care needs are addressed in a way, which is consistent, safe, and respectful, this ensures they are safe from harm. . This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans seen were variable in the detail they provided, some were good, detailing needs, and taking account of residents’ privacy, dignity and choices. Others were less detailed and lacked information around exactly what care staff were to provide. This could mean that staff do not have the information they need to ensure that residents needs are fully met. In discussion with staff they said that they read them and did find them useful when understanding how to deliver care to a person. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 12 In discussion with the people living in the home they said that staff were very kind and always helped them when they needed it. A requirement was made at the last inspection to ensure that care plans were kept under review in consultation with the resident or their representative. Some plans did provide evidence that families were involved in the creation and review of carer plans, however where a person is unable to be involved due to their lack of capacity it should be recorded to show why no involvement has taken place. This requirement is now met. Families spoken with said that the care plan had been discussed with them and information had been shared. Some people spoken with were aware of their care plan and the person most recently admitted said someone had sat with them and gone through how they wanted to spend their day and staff made sure that these choices were respected. The arrangements for supporting people with their health care were inspected to make sure that their safety and wellbeing is promoted and protected. Staff spoken with were aware of the importance of monitoring people’s health and knew who they needed to speak to should a person become unwell. Health care visitors were spoken with and said that staff contacted them appropriately if a person became unwell and followed plans where a person had a pressure ulcer. This shows that staff are supporting people with their pressure care needs. There is evidence around the home that different kinds of pressure relieving cushions and mattresses are provided to prevent or help manage pressure sores and provide people with comfort and relief. One person who lives in the home spoken with said her health is well looked after and she said she sees the Doctor when she needs to. Medication records were viewed to ensure that staff were administering medication according to the prescription. Records were mostly good with no gaps that were unexplained. Controlled drugs were stored separately from the main medication and were appropriately recorded by staff to ensure that people living in the home were protected. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 13 Staff spoken with said that only senior staff who had received training were allowed to administer medication and they felt that medication was handled safely by those staff. Staff were observed throughout the day working with residents speaking to them politely and generally interacting with them positively. People living in the home who were spoken with said that staff were always kind and polite and never shouted at them, they knocked on the door before entering and made sure the bathroom door was closed when they had a bath. This shows that staff are respecting their privacy and dignity. During a short period of observation of the people living in the home, they were mostly neat and tidy and those spoken with confirmed they wore their own clothes. Autumn Grange Care Home DS0000002190.V341208.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): 11, 12, 13 14 and 15 Quality in this outcome area is good. Some people have their lifestyle choices recorded and respected, and the social, cultural and recreational activities provided meet the needs of people who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From information provided prior to the inspection by the manager residents’ meeting are held every six weeks. During which they are asked bout all areas that affect their lives. Care plans viewed identified what religion someone was and that staff were to ensure that if they wished to participate in a church service they were to support them. Care plans also identified what time someone preferred to eat but from observation at lunchtime it appeared that all residents ate their main meal at Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 15 the same time, however in discussion with a person who was eating their afternoon tea in their room, they said they were able to eat in their room if they wished. Relatives spoken with confirmed this. People spoken with said that they were supported to make choices and staff spoken with understood that people who lived in the home had rights and part of that was the ability to choose what they did including if they had a bath that day and what time they got up. A requirement was made at the last inspection regarding consulting residents about what time they want to get up and go to bed. All residents said that they got up and went to bed when they wanted to. One person’s care plan identified that they liked going to bed later. The person could not confirm whether this as he did not speak English but staff spoken with were aware of this request and had cards with different phrases on to help with communication. This requirement is met. During the course of the day people were seen taking part in various activities including knitting, playing cards and painting. In discussion with the manager she was in the process of organising transport for residents to go out for the day staff and people living in the home were aware of these arrangements. Activities are still not clearly recorded, they are sometimes mentioned in diary notes but it is not always clear how a person has spent their day. This was recommended in the last inspection and will be made again as this helps staff know how residents spend their day and whether it is an interesting day that supports their sense of well being. Residents are able to personalise their bedrooms and this was noted during the partial tour and when people invited the inspector into their bedrooms. This shows that people are encouraged to feel settled and ‘at home’. Family and friends are welcomed and encouraged to visit and visitors were seen throughout the day. Relatives spoken confirmed that the manager had informed them they could visit whenever they wanted to and that staff always made them feel welcome offering them a hot drink. People who live in the home spoken with said that they mostly enjoyed the meals and that they were always given a choice. Pre inspection information said that where they had improved over the last twelve months was in trying to consult more with residents in menu planning. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 16 The home where possible makes arrangements to provide meals that are culturally appropriate, people living in the home confirmed this. But care plans do not always make clear that this is being done. The teatime meal was observed and residents were given a choice of sandwiches and cake as well as a hot drink. However residents spoken with said that they would like salad occasionally. Where people need support staff are available to provide this in a discreet manner and appropriate aids such as plate guards and suitable cutlery are provided so people can be as independent as possible in feeding themselves. Autumn Grange Care Home DS0000002190.V341208.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): 17 and 18 Quality in this outcome area is good. Residents’ concerns and complaints are responded to and investigated appropriately This judgement has been made using available evidence including a visit to this service. EVIDENCE: Complaints were inspected to check that any concerns raised are properly recorded, investigated and responded to. The complaints procedure is on display in the reception area and other parts of the home. It is also provided to a person as they move to the home this ensures everyone understands how to complain if they are unhappy with the service they receive. The Commission has received an anonymous complaint about this service and this was passed back to the Registered Person to investigate. In discussion with the manager it was clear there was no evidence to substantiate this complaint and appears to be of a malicious nature. People who live in the home all felt confident that they could raise concerns with the manager and that she would deal with them. Those who had needed Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 18 to complain in the past said that it had been dealt with and were happy with the outcome. Staff spoken with all knew what to do to support residents to make complaints and relatives spoken with said that the manager had explained how to complain and felt comfortable if they needed to. A requirement was made at the last inspection that the manager must follow local procedures for any protection of adults. There have been two incidents in the last twelve months and the manager has followed procedures and informed social service. There are copies of the Nottinghamshire Committee for the Protection of Vulnerable Adults procedures at the home, and staff said some staff have recently done training on Abuse issues to ensure they know about the types and signs of abuse. Staff also knew where the policies and procedures were kept and said that they had read them and knew what to do. All residents said that staff were kind and helpful they did not shout they were patient and caring. Relatives spoken with said they could not praise staff highly enough they were so kind. And they felt confident when they left their loved one that they were being well cared for. Staff had a good understanding of what abuse was and what they must do if they suspected it including taking things further if they did not feel they were being listened to. The managers now administer residents’ monies and residents are able to access their personal allowance when they want anything, staff spoken with said that only senior staff could sign for money and it was carefully monitored. Autumn Grange Care Home DS0000002190.V341208.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 and 26 Quality in this outcome area is good. The home is generally fit for purpose and action is taken to address concerns raised that may affect the well being of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the accommodation was made and a sample of bedrooms was seen to make sure that the home is clean, safe and comfortable for residents. Unit 3 has been redecorated and is much less institutional in its décor. There was new furniture in the dining room as well curtains and chairs and overall felt cleaner and brighter in all three units. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 20 Some bedrooms have been redecorated, double bedrooms have curtaining to ensure privacy and all bedrooms seen were personalised. It was noted that some bedrooms were dusty around the ornaments, people in those bedrooms said that the cleaner wasn’t always thorough. This was brought to the manager’s attention. The manager has received advice from the infection control nurse they have changed all the toilet rolls to large enclosed rolls and have gel dispensers and paper towels in all toilets. This ensures that the people who live in the home live in an environment that is as safe as possible. A requirement was made at the last inspection regarding the laminate flooring in the lounges. The manager has sought advice from the Falls Nurse and she has recommended that these areas be replaced as soon as funds allow. In the interim the risk assessments have been carried out to ensure that people must wear shoes or slippers when walking in that area. The requirement is now met. Information was provided in the business plan to show that what money is planned to be spent over the next financial year on renewal of furniture and decoration. The manager has recently carried out a quality survey and some feedback from this showed that 21 of the 21 replies (70 were sent out) were positive about the cleanliness, however areas of concern raised were in the laundry clothes being washed at wrong temperatures, slow turn around of clothes from the laundry, clothes given to wrong people and clothes going missing. It was also commented that there was smell of urine around the building. This was not noticed on the day of the inspection visit. An action plan has been developed to address the comments made in the quality survey, this shows that the manager and provider are listening to the people who live in the home and are willing to make improvements. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 21 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 good. Recruitment procedures are robust and protect residents from people who may abuse and training is in place to ensure that staff are competent to work in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From evidence seen in care plans diary notes and where possible in discussion with the people who live in the home that there are enough staff available to support them. Residents spoken with said that they felt staff were available when they needed them. There is always a senior person on each shift and a manager is on call 24 hours a day. The quality questionnaire carried out by the manager had comments from relatives who felt there could be more staff and a little more interaction between staff and residents. The manager is aware of these comments and is working with staff to improve the interaction. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 22 There are forty care staff employed at the home and thirty-six have either got or are in the process of getting their NVQ level 2. This exceeds the recommended minimum level of 50 and is to be commended. Evidence provided in the pre inspection information and from staff files showed that recruitment in the home follows equal opportunity policies and is robust. Each member of staff has their Criminal Records Bureau checks and two references before they start work. One file checked was from an oversees person, there were the appropriate home office checks and police check from their country of origin but no Criminal Records Bureau check from this country. In discussion with the manager she was unaware that this needed to be done and made arrangements for this to be done as soon as possible. This shows that manger is responsible and aware of the importance of appropriate safety checks to protect the people who live in the home. Each staff members’ file had a training analysis on which identified their training needs and what training had been completed. The evidence on staff files indicates that a great deal of training has been provided since the last key inspection and this is to be commended. Each member of staff undergoes induction and staff spoken with said that they access training and felt that the past year had been very good in getting staff trained and this was now paying off. This ensures that staff are trained and competent to work with people in the home. Staff were observed throughout the day interacting with the people who live in the home in a positive manner, however the quality survey stated that staff should give residents equal attention as they felt that some residents were seen as a nuisance. The manager is aware of this and is working with staff to improve interaction with the people who live in the home. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 23 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, 33, 35, 37 and 38 Quality in this outcome area is good. The manager is a caring and approachable person; systems are in both in place and being created to ensure the safety of the people who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is experienced and had managed the home for several years. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 24 The people who live in the home, staff and relatives praised her and all said she was kind, approachable and supportive. The registered manager has spent the months since the last inspection going through the requirements set by the Commission and the suggestions made by social services Contracts and Commissioning review officers to improve the care within the home. This shows her commitment to improving standards within the service. She has introduced a newsletter has sent out quality surveys and has created a clear method of feeding that information back to the people who live in the home, relatives and staff. There is a linked business plan to the survey that shows they are doing something about comments made within the survey. The responsible individual and the manger are open to suggestions and comments in improving the service and this is evident in the changes that have taken place over the last few months. Two requirements were made at the last inspection the first that the business plan is available and open to inspection and the second that the people who live in the home be able to keep their records up to date. A copy of the business plan was given to the inspector during the inspection visit and provides evidence of the work that the provider intends to carry out during this financial year as such this requirement is met. During the reading of care plans it was clear that where people are able to provide information to their care plans they are doing but it is not always clear that where they are not that this is due to their ability. Although the requirement is met a recommendation will made to ensure that it is made clear when someone is not involved in keeping their records up to date. The manager has taken over monitoring residents money to ensure that they have better access to it this is well recorded and stored safely. This was viewed and showed that all was correct with signatories and countersignatures. Ensuring the people who live in the home are safe from financial abuse. The staff have all completed their statutory training courses such as Moving and Handling, Infection Control and Fire Safety and they confirmed that their health and safety is promoted and protected by the provision of training and equipment. The records of Health and Safety servicing and checks were inspected to ensure that residents’ are properly protected. These were all up to date and well recorded. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 25 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 X 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 X 4 X 3 X 3 3 Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 26 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 2 3 4. 5. Refer to Standard OP3 OP7 OP7 OP12 OP14 Good Practice Recommendations Initial assessments should incorporate significant life events and cultural and religious needs to enable staff to better understand and support residents on admission. Where a resident is unable to take part in the creation or review of a care plan this could be recorded in the review. Care plans could explain in more detail the social and cultural and religious needs of the residents to ensure that people receive the holistic care they need. Record all activities residents take part in. Care plans should identify what time residents prefer to get up and go to bed. Autumn Grange Care Home DS0000002190.V341208.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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