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Inspection on 23/11/06 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 23rd November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Residents meetings, which started earlier this year, have continued and residents spoken with said that they found them very useful to bring any issues that concerned them to the attention of the management. The manager continues to cooperate with the Commission to improve standards in the home.Residents said that they had plenty of food and those with special dietary needs were met. Staff understand what constitutes abuse and what their responsibilities are if they witness it.

What has improved since the last inspection?

The manager has used a new format for care plans and they are significantly better in providing clear information on how to care for residents. The manager has introduced a `Memory File`, which has life history information about residents, their likes and dislikes and people and places that are important to them. This in turn informs the care plan. This is good practice. New Chairs have been ordered and some improvements were noted in the environment such as new laminate floor in the living areas. Observation during the inspection showed that there was an improved level of interaction between staff and residents, which residents spoken with said they appreciated.

What the care home could do better:

The Registered Person must ensure that the good work that has been achieved on care planning is built on and reviews are carried out to ensure they remain up to date. Although residents are generally happy with the care they do not feel that they are in control of their lives and they are unable to influence the routine of the home, although it was acknowledged that the Resident`s Meetings were helping. The Registered Person must always inform the Adult Protection Unit about any incident that may be judged as abuse against a resident to ensure that they follow appropriate local procedures. Concerns were raised over the safety of the new laminate flooring by health care staff and the Registered Person must ensure that every effort is made to minimise the risk residents may be at from falling.The Registered Person must provide evidence that the home has sufficient funds to carry out the objectives set out in its statement of purpose, such as ongoing training for staff and maintenance. Residents are aware of their care plans but they are still not involved in their maintenance and the Registered Person must ensure that where possible residents are given opportunities to do this.

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 23rd November 2006 09:45 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.V320623.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.V320623.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.V320623.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 supernumery 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. 13th June 2006 Date of last inspection Brief Description of the Service: The fees for 2006/07 are £307.92. 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.V320623.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key inspection of the inspection year 2006/07; it was unannounced and was carried out by one inspector over 9 ½ hours. A random unannounced inspection was also carried out on 13th June 2006. This report is not published but a copy is available to the public on request. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for clients and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting residents and tracking the care they received through looking at their records, talking with them where possible, and observing staff that provide their care. A partial tour of the building took place and the bedrooms of residents’ who were case tracked were inspected. Residents’ and staff records were inspected and visitors, residents and staff on duty were spoken with. The Commission received an anonymous allegation regarding a possible adult abuse incident, concerning a member of staff hitting a resident. It was alleged that the staff member was not suspended whilst the incident was investigated, contrary to correct procedure. This allegation is dealt with in the body of the report. Other information that was used to inform this report includes accident and incident reports received since the last inspection as well as the previous inspection report. Information had also been received by the Commission from social services and health care workers regarding poor care practice. Firstly the number of accidents that appeared to be happening in the home and secondly the inappropriate discharge and subsequent poor care of two residents from hospital back to the home These issues will be dealt with in the body of the report. What the service does well: Residents meetings, which started earlier this year, have continued and residents spoken with said that they found them very useful to bring any issues that concerned them to the attention of the management. The manager continues to cooperate with the Commission to improve standards in the home. Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 6 Residents said that they had plenty of food and those with special dietary needs were met. Staff understand what constitutes abuse and what their responsibilities are if they witness it. What has improved since the last inspection? What they could do better: The Registered Person must ensure that the good work that has been achieved on care planning is built on and reviews are carried out to ensure they remain up to date. Although residents are generally happy with the care they do not feel that they are in control of their lives and they are unable to influence the routine of the home, although it was acknowledged that the Resident’s Meetings were helping. The Registered Person must always inform the Adult Protection Unit about any incident that may be judged as abuse against a resident to ensure that they follow appropriate local procedures. Concerns were raised over the safety of the new laminate flooring by health care staff and the Registered Person must ensure that every effort is made to minimise the risk residents may be at from falling. Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 7 The Registered Person must provide evidence that the home has sufficient funds to carry out the objectives set out in its statement of purpose, such as ongoing training for staff and maintenance. Residents are aware of their care plans but they are still not involved in their maintenance and the Registered Person must ensure that where possible residents are given opportunities to do this. 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.V320623.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.V320623.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 4 Quality in this outcome area is good. Residents or relatives are provided with information to make informed choices about entering the home. Each resident has a written contract/statement about the conditions within the home. No resident moves to the home without having had his/her needs assessed and been assured that these will be met. Residents know that their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 10 The current statement of purpose is being updated and was not available for inspection. However in discussion with the manager it was clear that the document does not identify the limits of the service. It is recommended that the Registered Person include in the statement of purpose some information on the limits of the service the home is able to provide. Residents spoken with said that they were able to visit the home before hand and had been given information about the home, or a relative had visited on their behalf. One resident said that they had visited lots of homes before coming here and said they had made their decision because ‘this home gave me a good deal of freedom’. Each resident has a contract, which details what the fees are, room to be occupied and rights of the resident. Each resident whose care plan was viewed for the purpose of this inspection had an assessment, which covered the relevant areas to enable staff to create a care plan that supports the residents’ needs. The requirement set at the last key inspection has now been met. A requirement was set at the last key inspection to ensure that where residents had specific needs linked to their dementia this was recorded on their plan, from care plans viewed this requirement has now been met. A requirement was made at the last key inspection to ensure that where residents from different ethic backgrounds did not want their cultural needs meeting this needed to be recorded on their plans. From evidence provided this has been met. Autumn Grange Care Home DS0000002190.V320623.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’ needs are set out in individual plans. Residents’ health needs are fully met. Residents where appropriate, are fully responsible for their own medication and are protected by the homes policy and procedures for dealing with medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made at the last key inspection to improve the detail in care plans. Four care plans were viewed as part of this inspection. Each plan used the new format and provided clearer information on what the residents’ needs were and what staff needed to do to meet the needs. There are clear Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 12 risk assessments paying particular attention to falls. From evidence seen this requirement is met and ensures resident safety. However the plans viewed had not been reviewed since the new format had been introduced and therefore if residents’ needs had changed this would not have been identified. The Registered Person must ensure that plans are reviewed regularly and that residents and their representative are involved where possible to ensure changing needs are identified and met. The manager provided evidence that a ‘Memory Book’ is being created with residents and relatives that include the history of the resident, with photographs, their likes and dislikes as well as what is important to them. This document is used to inform the care plan. This is good practice. Residents spoken with said that although they had not seen their care plan ‘there’s no secret about them, they are there if I want to see them’. A second requirement was made regarding care plans to improve the clarity and clearly define what residents assessed needs are. From evidence seen in care plans this requirement is now met. A requirement was made regarding ensuring plans were kept under review where resident weight changes significantly. Evidence was seen that the manager has introduced new weight record charts, which lead the person to take action if weight changes. This requirement is now met. There was evidence that where care plans detailed residents’ nutritional needs were compromised due to ill health, fluid and diet intake charts were being used to monitor the situation ensuring that their needs could be met and any concerns quickly dealt with. Concerns had been raised by a social worker and district nurses following the discharge from hospital of two residents whom were no longer weight bearing. Two residents recently discharged from hospital now require hoisting. Autumn Grange appeared unprepared to meet either of their needs and say that they cannot manage to hoist residents on a long-term basis. Autumn Grange claim they were not informed of the change in circumstances prior to discharge, the wards are claiming that they had informed Autumn Grange. Evidence was seen at the home of notes taken by the manager following a telephone conversation with the hospital regarding the discharge of the first resident. It makes no mention of the person needing hoisting and the manager confirms that the ward staff at no time mentioned the person’s mobility had decreased to such a level they would require a hoist. Records indicate that contacts were made with outside agencies to try to ensure the residents’ needs were met. From the evidence seen the staff appeared to Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 13 doing all they could to provide appropriate care. A new care plan has been created for the residents and staff were observed providing support in the residents bedroom throughout the day. A resident said that their legs were swollen and was supposed to wear special tights but the laundry had lost them. The inspector followed this up with the manager. The resident no longer needed the tights and had been informed of this, the care plan reflected this change in needs and that the GP had been contacted in relation to the swollen legs. This ensures that residents’ health care needs are being met appropriately. A requirement was made at the last key inspection regarding risk-assessing residents’ ability to self medicate. The new care plan format includes this for all residents and evidence was seen where residents were self medicating support was given. This requirement is now met. Residents spoken with said that they had no problem in receiving their medication. Staff were observed throughout the day interacting with residents, they were polite and helpful. Residents spoken with said that staff were ‘kindness itself’. A visitor also said that staff were lovely and very helpful with her relative, saying ‘all the staff have been brilliant’. Residents’ privacy and dignity is supported by staff. Autumn Grange Care Home DS0000002190.V320623.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 and 15 Quality in this outcome area is adequate. The lifestyle experienced by residents in the home is not always to their preference or expectation. Residents are able to maintain contact with family/friends and representatives. Residents are not always helped to exercise choice and control over their lives. Residents receive wholesome appealing balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager introduced Residents meeting earlier this year and in discussion with residents it was clear that they are very popular and are seen as a good way of raising concerns or issues. Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 15 Residents did say that although some activities are provided ‘you still sit a long time doing nothing’. Residents did mention one member of staff as being very good at arranging activities with them like playing scrabble and knitting but that other staff were not as good as her in doing things. Each unit had a list of daily activities and evidence was seen that some residents were involved in some activities during the day. The review officer who visited in August 2006 commented that no records were made of what activities residents take part in. This practice still has not started and it is strongly recommended that the Registered Person make arrangements for this to take place. Residents said that often there is no choice about what time they get up and go to bed. They are not given an opportunity to lie in if they want to or have breakfast in bed. In discussion with residents there appeared to be some rigidity in the routines of daily living. The Registered Person must ensure that routines are flexible and varied to suit the residents’ expectations, preferences and capacity. A requirement was made at the last key inspection regarding residents wishes to attend religious services, evidence was seen that arrangements have been made for someone to come to the home to meet the spiritual needs of residents. This requirement is now met. Residents spoken with said that their family and friends are always made to feel welcome and can see their visitors in private if they need to. Residents said that visitors can come any time during the day, the manager confirmed this; however saying that they encourage visitors to come outside lunchtime as residents are often busy. Residents spoken with said that the food was good and there was a choice of two hot meals at lunchtime as well as salad. There is always a cooked breakfast and there is plenty of it. The evening meal was observed and sandwiches and cakes were seen being taken round to residents. One resident commented that ‘the soup is always nice’. The same resident commented that as a diabetic they needed a snack before going to bed and was not getting this, however in discussion with the manager and evidence from care notes it was clear that snacks were available for all residents who had diabetes, ensuring that their blood glucose levels were maintained throughout the night. The cook was spoken with and he understood how to support people with dietary needs and that diabetics were provided with choices to support their needs. Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is good. Residents and their families are confident that their complaints will be listened to, taken seriously and acted upon. Residents’ legal rights are protected. Although residents are protected from abuse not all procedures are followed correctly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken with were very positive about how management respond to complaints. ‘We are not frightened to speak up’. ‘You can say what you want to say’. ‘If you take a problem to Nora it will be dealt with’. A requirement was made at the last key inspection to ensure that people who want to complain are not told to put it in writing. In discussion with staff it was clear that they understood how to support residents and relatives if they wanted to make a complaint. The home has not received a complaint since the last key inspection in April 2006. From the available evidence this requirement is met. Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 17 Evidence was seen in care plans that residents are registered for Postal Votes and participate in the civic process if they so wish. The Commission received an anonymous complaint on 6th November 2006 regarding a safe guarding adults’ issue. It alleged that a care worker slapped a resident and that the staff member was not suspended pending investigation as per policy and procedure. This matter was looked at during the inspection and evidence was seen that the home did suspend the staff member and evidence of interviews with staff was also seen. The allegation was of a malicious nature and no evidence could be found that this member of staff had slapped anyone. As such the complaint is not upheld. However, the manager failed to notify the Adult Protection Unit, as local procedure requires. The Registered Person must ensure that appropriate arrangements to inform Adult Protection Unit are made and carried out promptly. A requirement was set at the last key inspection regarding where staff work with residents with challenging behaviour that they should receive appropriate training to support them. Staff spoken with said that they attended courses on Dementia Care and Abuse of the Elderly and were due to attend a course on Challenging Behaviour shortly. From available evidence this requirement is now met. Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 18 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 24 and 26 Quality in this outcome area is adequate. Residents live in a safe environment but it is only maintained to an adequate standard. Residents’ bedrooms have suitable bed linen and are comfortable. The home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two requirements were made at the last key inspection. Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 19 1. Ensure that all identified hazards created by poor maintenance are corrected. During the tour of the building some improvements were noted in the environment. New floors had been laid in the living areas of each unit, evidence of repairs to various areas was provided. The requirement set is now met. In discussion with the healthcare workers concerns were raised over the safety of the new laminate flooring particularly where residents did not wear shoes or slippers. It was felt that there had been an increase in the number of falls since this new flooring had been laid. The Registered Person must ensure that all parts of the building residents have access to be safe and free from hazards. 2. A programme of routine maintenance and renewal of the fabric and decoration of the premises must be produced and implemented with records kept. The manager advised that although they have no plan of routine maintenance the provider repairs things as required. Evidence was seen during the tour that some areas of the building were being repaired or redecorated. Although this deals with the problem it is not preventative and it may mean residents have to live with a poor environment before arrangements can be made to make repairs. The Registered Person must also be aware of general damage to the building particularly on doorframes where wheelchairs have caused significant damage. Although the requirement is not met, because evidence was seen that repairs and maintenance are taking place the requirement for a programme of routine maintenance will be changed to a recommendation. Overall the environment is accessible and safe it is not always homely and comfortable. A recommendation was made at the last key inspection to employ a maintenance man. This recommendation is made again. Residents spoken with said that they thought their bedrooms were all right, and one commented that ‘it was dark’ and as they were partially sighted it made it very difficult to see. This was raised with the deputy manager who arranged for a higher wattage light to be fitted. A resident commented that the home was cold and the heating wasn’t put on. However in discussion with other residents all agreed that the home was always warm and if they ever did feel cold staff would arrange for the heating to be put on or a rug round their legs if it was draughty. ‘My bedroom is always nice and warm’ commented on resident. Some residents spoken with felt that the home looked ‘scruffy’, particularly the communal areas. Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 20 A requirement was made at the last key inspection to provide new bed linen, pillows and chairs. Evidence was provided that new chairs were on order and due to be delivered in the next few weeks. During a tour of the building the pillows noted on residents beds were not lumpy and bed linen was of an acceptable standard. This requirement is met. The home was free from offensive odours on the day of the inspection and the laundry is sited so as not to intrude on residents. The laundry floor and walls are impermeable so as to ensure they can be cleaned easily. A requirement was set at the last key inspection not to use baths as sluices. Discussion with staff showed that they understood where to sluice soiled clothes to minimise risk of infection. This requirement is met. Autumn Grange Care Home DS0000002190.V320623.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 and 30 Quality in this outcome area is good. Residents’ needs are met by the numbers and skill mix of staff. Residents are supported by competent staff. Staff receive training to enable them to perform they job. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made at the last inspection to ensure staff are employed in sufficient numbers to meet the dependency needs of residents. On the day of the inspection staff were observed sat with residents and spending time involved in activities other than providing care. Residents spoken with said that staff were available to help them and that they didn’t usually have to wait long before someone came if they called them. Staff were observed throughout the day responding to bell calls promptly. From available evidence the requirement is met. Evidence was provided to show that staff are encouraged to attend NVQ level 2 training and staff spoken with had NVQ level 2 and some were hoping to Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 22 progress to NVQ level 3. This ensures that residents benefit from competent and well trained staff. In discussion with staff and the manager evidence was provided that staff have access to a wide variety of training, including all mandatory training such Food Hygiene, Moving and Handling as well as more specific training to assist with their roles as carers, again this ensures residents are supported appropriately by well trained staff. Autumn Grange Care Home DS0000002190.V320623.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, 32, 33, 34, 37 and 38 Quality in this outcome area is good. Residents live in a home, which is managed by a person fit to be in charge. Residents’ benefit from the leadership and management. This home is mostly run in the best interests of the residents. Evidence is not available regarding the accounting procedures within the home. Residents are not always safeguarded by the home’s record keeping or policies and procedures. The health safety and welfare of residents and staff of mostly promoted and protected. This judgement has been made using available evidence including a visit to this service. Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 24 EVIDENCE: A requirement was made at the Random Unannounced inspection in June 2006 regarding ensuring clear lines of accountability within the home and that all staff adhere to these lines of accountability, and are aware of the policies, procedures and codes of conduct expected of all staff. It was evident from discussion with staff and both the manager and deputy manager that staff were being made aware of their responsibility to understand codes of conduct as well as policy and procedures. It was also clear that new recruitment had been ongoing to improve the quality of staff employed in the home. From available evidence the requirement is met. Staff spoken with said that the manager provided a clear idea of what standard of care was expected and that resident’s welfare must be first priority. Staff spoken with said that they felt it was a well run home. A requirement was set at the last key inspection, which remains outstanding from 31/07/05. This requires the Registered Person to maintain a quality assurance system that reviews and improves the quality of care at the care home. Although not formalised, the work the manager has been carrying out over the last few months, ensuring residents meetings take place and that the outstanding requirements are met, goes towards meeting this standard. Sufficient attention has been made to improving the quality of the service to evidence that this requirement is met. A requirement was set at the last inspection regarding the business plan being open for inspection. This was because no evidence was found of planned maintenance or training budgets. During this inspection the business plan was not available and the requirement will be carried over and the Registered Person must make it available to the Commission by the date set. A requirement was set at the last key inspection to ensure that all service users are able to access their care plan and record where they have declined the opportunity. Residents spoken with confirmed that they knew they had care plans and that they were able to access them if they wanted to. However plans still do not show that residents are fully involved with maintaining their personal records if they so wish. The Registered Person must ensure that where appropriate residents are consulted over their care plans. Although the requirement that was set is met a new requirement will be met to ensure that the Registered Person provides evidence that residents are consulted with. Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 25 Evidence was seen that staff receive mandatory training and that appropriate maintenance is carried out on equipment within the home to ensure residents and staff safety. Currently accident records are stored in individual residents care plans. Although this meets the Data Protection Act 1998 for the storage of confidential information it does make auditing the information very difficult. It is recommended that the manager keep a copy of all residents’ accidents in separate file to enable prompt auditing of accidents and to carry out any remedial action to minimise the risk to residents. The manager ensures that the Commission is notified of any incident that adversely affects the residents and safety procedures are posted around the home. This means that staff and resident safety is focused on and maintained. Autumn Grange Care Home DS0000002190.V320623.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 3 3 3 X X X 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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X X 2 3 Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(2) (b)(c) Requirement The Registered Person shall keep the resident’s care plan under review in consultation where appropriate with the resident or their representative. The Registered Person shall so far as practicable enable service users to make decisions with respect to the care they are to receive and their health and welfare. Residents must be consulted on the routines within the home that directly affect them including what time they go to bed and get up. The Registered Person shall ensure that the home is conducted so far as to promote and make proper provision for the health and welfare of residents. Where an allegation of abuse is made the adult protection unit must be notified as per local agreements. The registered person shall ensure that all parts of the home to which residents have access DS0000002190.V320623.R01.S.doc Timescale for action 11/01/07 2 OP12 12(2)(3) 11/01/07 3 OP18 12(1)(a) 11/01/07 4 OP19 13(4)(a) (b)(c) 11/01/07 Autumn Grange Care Home Version 5.2 Page 28 5 OP34 25(1) are so far as practicable free from hazard to their safety. Where residents are at risk of falls on the laminate floor risk assessments must take place and action taken to minimise that risk. The Registered Person shall carry 11/01/07 on the care home in such a manner as is likely to ensure that the care will be financially viable for the purpose of achieving the aims and objectives set out in the statement of purpose. The business and financial plan must be open to inspection. (Outstanding Requirement 04/04/06) 11/01/07 The Registered Person shall where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his, revise the service users plan. Evidence that residents are involved in maintenance of their personal records must be provided. 6 OP37 15(2) 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 Refer to Standard OP7 OP12 OP14 Good Practice Recommendations Care plans should be reviewed at least once a month. Record all activities residents take part in. Care plans should identify what time residents prefer to get up and go to bed. DS0000002190.V320623.R01.S.doc Version 5.2 Page 29 Autumn Grange Care Home 4. OP19 The Registered Person employs a maintenance person. . (Outstanding from inspection on 04/04/06) A programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced and implemented with records kept. It is strongly recommended that the registered person establish staff training and development programme with sufficient budget to enable staff to be fully trained to meet residents’ needs. . (Outstanding from inspection on 04/04/06) Store residents’ accident records centrally to improve auditing of accidents. 5 OP19 6. OP30 7 OP38 Autumn Grange Care Home DS0000002190.V320623.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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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