Inspection on 30/06/08 for Autumn Grange Care Home

This inspection was carried out on 30th June 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Autumn Grange Care Home 15/12/08

Autumn Grange Care Home 02/10/08

Autumn Grange Care Home 15/08/07

Autumn Grange Care Home 23/11/06

Autumn Grange Care Home 04/04/06

Autumn Grange Care Home 10/11/05

Autumn Grange Care Home 18/08/05

Autumn Grange Care Home 16/06/05

Autumn Grange Care Home 24/02/05

Autumn Grange Care Home 15/09/04

Autumn Grange Care Home 04/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Autumn Grange Care Home 19-29 Herbert Road Sherwood Rise Nottingham NG5 1BS Lead Inspector Karmon Hawley Unannounced Inspection 30th June 2008 09:00 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.V367444.R03.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.V367444.R03.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 8417470 0115 9620061 autumngrange@btconnect.com Sherwood Rise Ltd Manager post vacant 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.V367444.R03.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. 15th August 2007 Date of last inspection Brief Description of the Service: 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. The current basic weekly fees for the service is £329. The most recent inspection report can be found in the entrance hall. Autumn Grange Care Home DS0000002190.V367444.R03.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 1 star this means that people who use the service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people living at the home 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. One regulatory inspector conducted the unannounced visit over 1 day, including the lunchtime period A review of all the information we have received about the home was considered in planning this visit and this helped decide what areas were looked at. The main method of inspection we use is called ‘case tracking’ which involves selecting the care plans of 4 people and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. The registered provider, members of staff and people who use the service were spoken with as part of this visit. A partial tour was undertaken by the regulatory inspector, which included looking at the bedrooms of those people who we case tracked and communal areas of the home. What the service does well: People using the service spoken with said, ‘the staff are generally here to help me if I need them,’ ‘the staff are very good, kind and helpful,’ and ‘the staff help me, I have everything I need, I am settled here.’ People using the service are supported in accessing specialist services such as the doctor and district nurse to ensure that their health care needs are met. There are contacts with the wider community such as the stroke association and day centres specific to the needs of people using the service. People using the service said that they are able to have visitors at any time and that these may be received in private should they wish. Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 6 There are sufficient staff available to meet the needs of people using the service. Staff spoken with said, ‘the staffing levels are much better, there are enough staff available to meet the needs of people,’ ‘It can be very busy and hard work but there is enough support and people from other units will help you if needed.’ People using the service said, ‘there are generally enough staff here, they help me when needed,’ the staff are very good, they help me all the time,’ and ‘the staff are usually around if I need something.’ Staff spoken with were able to discuss the individual needs of people using the service and how they support them in meeting these. What has improved since the last inspection? Additional support and advice has been obtained in regard to improving the care planning process to work towards ensuring that these are in place for all the highlighted needs of people using the service. There has been some development in risk assessments working towards ensuring that people using the service remain safe. A training matrix has been completed to show the training and development that staff have undertaken and require to ensure that they have the required knowledge and skill to meet the needs of people using the service. The duty rota has been made clearer and the deployment of staff changed to make sure that sufficient staff are available to meet the needs of people using the service. The recruitment processes have been reviewed and all staff now have the correct documentation in place to ensure that people using the service are protected from unsuitable people being employed. A clear picture of the training and development that staff have and need to undertake has been made available, showing the areas that require attention to ensure that people using the service are cared for by people who are well trained to carry out their job role. Staff supervisions sessions have begun to develop to ensure that good working practices are carried out and people using the service remain safe. The fire doors have now been repaired to ensure that people using the service are protected should an outbreak of fire occur. The Commission for Social Care Inspection is now made aware of all significant issues occurring within the care home so that we can monitor the outcomes for people using the service. Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 7 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.V367444.R03.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.V367444.R03.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area has not been assessed during this visit. This judgement has been made using available evidence including a visit to this service. The service is currently unable to admit people into the care home therefore a judgement of this outcome area is unable to be made at present. The service does not offer intermediate care. EVIDENCE: The service is currently unable to admit any new people into the care home until outcomes for people using the service have been improved upon and the department of Adult Services Housing and Health have lifted a suspension paced upon the service. The Adult Services Housing and Health informed CSCI that this suspension was lifted on 14th August 2008. Intermediate care is not provided at the home and this standard is not applicable. Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 10 Autumn Grange Care Home DS0000002190.V367444.R03.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 adequate. This judgement has been made using available evidence including a visit to this service. As work on care planning and risk assessments is still ongoing, people’s needs may not be fully met and they may not be fully protected from highlighted risks. Due to the current medication practices, until resolved people using the service are not fully protected by the medication procedures in place. EVIDENCE: A requirement was set at the previous visit in regard to ensuring that plans of care are in place for complex care needs such as diabetes mellitus and dementia. There was very little written evidence within plans of care to demonstrate that compliance with this requirement had been achieved, however there was evidence to show that an audit of the care plans and the work needed to improve these had taken place. Individual likes, dislikes and needs had been highlighted in assessments that had taken place, however this information had not been fully utilised within plans of care. Within a plan of care where there were concerns in regards to Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 12 diabetes mellitus and the person’s health and wellbeing a specific plan of care was still not in place to ensure that care needs are fully met. The outreach team (a specialist service for people with dementia care needs) have been working with people using the service and staff to further develop care plans to ensure that they cover each person’s individual needs so that these are met. There was evidence available to show that two by this team have taken place. A requirement was set at the previous visit in regard to ensuring risk assessments are in place for all identified risks to ensure that people using the service remain safe. On examining plans of care there was evidence to show that work has taken place and a number of risk assessments are now in place. However within two plans of care where risks due to complex care needs, such as diabetes mellitus and behaviour that is challenging had been identified there were no risk management plans in place to address and managed these concerns. People using the service spoken with said, ‘the staff are generally here to help me if I need them,’ ‘the staff are very good, kind and helpful,’ and ‘the staff help me, I have everything I need, I am settled here.’ Staff spoken with were able to discuss the individual needs of people using the service and the level of support that each person requires to ensure that their needs are met. They could discuss the necessity of ensuring that a diabetic diet is maintained for those people who need it and the how they would support people if they became unwell due to diabetes mellitus. There was evidence within the plans of care examined to show that people using the service have access to specialist services such as the district nurse and doctor. One person using the service spoken with said, ‘I can see the doctor if I need to, the staff will contact him for me, I have seen them recently and had new painkillers which are better.’ Two dieticians were visiting the care home on the day of the visit to assess the nutritional needs of people using the service to ensure that people receive additional supplements to their main diet if needed. Medication records examined showed a number of errors, such as medication being administered but not signed for, medication not being administered but signed for as given and medication being omitted with no explanation given. One person using the service said, ‘staff give me my painkillers when I need them, they look after it for me, which I am happy about.’ There was evidence available to demonstrate that the acting manager has began an audit of the medication and the practices within the care home to highlight and address issues of concern. Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 13 Throughout the visit staff were observed to speak with people using the service in a respectful manner and address them politely. People using the service said, ‘ the staff are kind to me, I am settled here,’ and ‘the staff are polite, the new manager Emma is the right sort of person to push things to make sure that things are improved.’ Staff spoken said ‘we always make sure that people are covered when offering support with personal care and knock on people’s doors before we go in.’ Autumn Grange Care Home DS0000002190.V367444.R03.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. This judgement has been made using available evidence including a visit to this service. People using the service would benefit from more structured activities directed toward their individual needs to ensure that they experience a lifestyle that satisfies their needs. People using the service are supported and enabled to maintain contacts with people that are important to them. EVIDENCE: People using the service said, ‘I am happy and settled here, I enjoy watching the television and like to go to my room in the evenings to do this, we used to have more games and I would like more to do, but not in groups as people tend to argue,’ ‘I can look out of the window into the beautiful gardens, I go to church by myself,’ ‘we don’t tend to do that much, I spend my time watching the television,’ and ‘I enjoy reading and knitting, I am not really that bothered with activities.’ A number of people using the service were seen to play a ball game in the afternoon with a member of staff, others were generally watching the television or occupying themselves, there were no other activities on offer this particular day. Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 15 Staff spoken with said, ‘we spend time with people doing activities such as dominoes, and painting, however more activities are needed,’ and ‘we take people out when we have a chance, but there needs to be more for them to do.’ Relatives expressed in the most recent quality assurance questionnaires and at the relatives meeting that they felt that more activities were needed to stimulate people using the service. There are contacts with the wider community such as the stroke association and day centres specific to the needs of people using the service. Staff spoken with were able to discuss the differing needs of people living in the care in home. They stated that some people attend church or religious groups as they wish. Both staff and people living in the care home stated that the routine of the home was flexible and people could make decisions as able as to how they spend their time. During the visit people using the service were seen to spend their time as they wished. A variable menu is on offer to people using the service, however this is currently under review to ensure that people have more choice in what they eat. People using the service offered the following comments, ‘the food is generally ok, I am satisfied as I have not had much before,’ and ‘the food is alright, I have enough to eat.’ Staff spoken with were able to discuss the special diets that people using the service have and the reasons why they needed them. Several people using the service have been seen by the dietician and a nutritional assessment has been carried out to ensure that they receive a nutritious and balanced diet. Autumn Grange Care Home DS0000002190.V367444.R03.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service are assured that their complaints will be listened to and addressed. People using the service not fully protected from abuse due to the ongoing training needs of some staff. EVIDENCE: Three complaints have been received since the previous visit, in regard to maintenance and the standards of care. There was evidence available to show that these had been investigated and resolved. One person using the service said, ‘I do not have any complaints, but I do know who I need to talk with if I do.’ Staff spoken with were able to discuss what they would do should they receive a complaint and they said, ‘we would make sure that the management know if there are any problems and make sure that we sort them out if we can.’ Fourteen safeguarding allegations had been made since the last key inspection, five of which had been reported by the service. These were in regard to the standards of care; time responding to accidents, a lack of dignity and respect offered to people using the service and accidents and injury to people using the service. Because of this a meeting was held with the provider, acting manager, the department of Adult services Housing and Health and the Commission for Social Care Inspection. Following this a random inspection took place on 13th May 2008 and eight requirements were set to address issues of Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 17 concern. Seven of the allegations were founded with an outcome of unintentional neglect and appropriate action has been taken to prevent reoccurrence; seven allegations were unfounded. This report outlines the progress made in regard to these requirements. A requirement was set at the previous visit in regard to staff undertaking training in safeguarding of adults and working practices to be monitored to ensure that people using the service remain safe. There was evidence that twelve members of staff have undertaken training in safeguarding adults, the acting manager stated that this number was in fact higher, however these figures would not be logged on the matrix until certificates have been obtained. Staff spoken with said that they felt that more training is needed, out of the three members of staff spoken with none had undertaken this training, however they were able to briefly discuss the main principles in ensuring that people remain safe from abuse and their roles in ensuring that this happens. One person using the service said, ‘ I have everything I need here, I feel safe and settled.’ Autumn Grange Care Home DS0000002190.V367444.R03.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service live in a comfortable environment and they know benefit from the improved laundry service. EVIDENCE: A new kitchenette has been fitted into unit one so that people using the service are able to take part in domestic activities and use this, as they are able. General improvements continue to take place in the care home and some new furniture has been brought to ensure the comfort pf people using the service. The care home was generally clean and tidy throughout and one person using the service spoken with said, ‘it is always clean and tidy.’ The laundry room was clean and tidy and the ironing room was more organised. Each person using the service has an individual box where their laundry is placed before it is taken back to their room. One person using the service spoken with said, ‘staff look after all my washing and ironing for me, I am happy with this service.’ Autumn Grange Care Home DS0000002190.V367444.R03.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 good. This judgement has been made using available evidence including a visit to this service. There are sufficient staff available to meet the needs of people using the service. People using the service are now protected by the recruitment practices in place. EVIDENCE: A requirement was set at the previous visit in regard to the duty rota being a clear and accurate reflection of the staff on duty to ensure that sufficient staff are available to meet people’s needs. To address this issue and ensure compliance the staff rota has been reorganised so that staff are allocated to each unit according to the care needs of the people using the service. Staffing times have also been readdressed to ensure that staff have time for a handover session before they start their shift to ensure continuity of care. Staff spoken with said, ‘the staffing levels are much better, there are enough staff available to meet the needs of people,’ ‘It can be very busy and hard work but there is enough support and people from other units will help you if needed.’ People using the service said, ‘there are generally enough staff here, they help me when needed,’ the staff are very good, they help me all the time,’ and ‘the staff are usually around if I need something.’ Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 20 Staff files examined showed that all contained the necessary documentation required by law to ensure that people using the service are protected from unsuitable people being employed. All staff spoken with were able to confirm that they had undertaken the necessary checks such as criminal record bureau checks before they had commenced employment. The requirement set at the previous visit in regard to ensuring that all staff have the necessary checks in place has been met. A training matrix has now been completed which demonstrates that more training has taken place then originally expected. However there remain deficits in mandatory areas, which has been acknowledged by the acting manager. Evidence of plans to address these issues and training dates that had been arranged to rectify these deficits was seen, which demonstrates part compliance with the requirement set at the previous visit. Staff spoken with said that they felt that more training would be beneficial to ensure that they had all the necessary knowledge and skills needed to care for people living in the care home, they felt that they had learned most of their skills through experience and would now like more training to assist in their development. One person using the service said, the knowledge and skills of the staff working at the care home was variable.’ Autumn Grange Care Home DS0000002190.V367444.R03.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): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service now benefit from a more stable management structure and they are supported more in expressing their views and opinions about the service that they receive. EVIDENCE: The acting manager has previous experience in the care sector. She commenced her role on the 2nd June 2008 and has yet to make an application to become the registered manager. People using the service said, ‘I have met the new manager, she is very nice,’ ‘the new manager is of the right sort, she will make the necessary improvements,’ and ‘the new manager has introduced herself to me, she is very nice.’ Staff spoken with said, ‘the new manager has made some changes already, all of which are for the best,’ things are beginning to improve,’ and Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 22 ‘the new manager is approachable, she has made necessary changes to help bring up the standards of care.’ A meeting has been held for relatives of the people using the service so that they could be informed of the changes that are currently happening in the care home and the concerns that had arisen previously. There was evidence available to show that people had been informed of the concerns and the proposed action to remedy these. Relatives were given the opportunity to express their views some of which are as follows; ‘there is a lack of activities, the problem is due to a lack of organisation,’ ‘we would like special arrangements such as birthdays to be addressed,’ ‘the staff need to be managed and trained properly,’ and ‘we would like to be kept more informed of events.’ There was evidence that these issues had been discussed at the staff meeting and action plans highlighting who is responsible for what were in place to address concerns. The acting manager has carried out several audits such as care planning, staff personnel files and medication and has highlighted the areas that need addressing. The personal allowances checked on the day of the visit were all correct. Receipts are available for all transactions, however only one member of staff sign for these. One person using the service was observed to approach a member of staff and request some money out of their account, this was dealt with. A requirement was set at the previous visit to ensure that staff are appropriately supervised to ensure that they carry out good working practices and people using the service remain safe. The acting manager has made some progress on this and has been meeting with staff on an individual basis, she is also working on the floor on a daily basis to observe working practices. Relevant maintenance and servicing for equipment such as the lift and hoist are taking place to ensure that these remain in good working order. The fire doors noted at the previous visit have been repaired, however there were chairs placed so near to these fire doors that if these released they would still not be able to close due to this restriction. This was discussed with the acting manager who made arrangements to deal with this immediately. Staff spoken with were able to discuss the health and safety issues in regard to manual handling and the safe use of the hoist. Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 23 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 Four personal CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement People using the service must have plans of care in place for complex care needs such as diabetes mellitus and dementia to ensure that they are supported appropriately and their care needs are fully met. Risk assessments must be in place for all identified risks to ensure that people using the service remain safe. Arrangements must be made for the safe administration and recording of medication to ensure that people using the service are protected and receive their medication as prescribed. People using the service must be consulted with to make arrangements for stimulating activities to ensure that their needs are met. Further training in safeguarding adults must be arranged to ensure that people using the service remain safe. Further training in mandatory areas must take place to ensure DS0000002190.V367444.R03.S.doc Timescale for action 30/08/08 2 OP7 13(4,c) 30/08/08 3 OP9 13(2) 30/08/08 4 OP12 16(2,m,n) 22/10/08 5 OP16 13(6) 30/08/08 6 OP30 18(1,c,i) 22/10/08 Autumn Grange Care Home Version 5.2 Page 25 7 OP31 8(1) that staff have the necessary skills and knowledge to meet the needs of the people using the service. The acting manager must make 30/08/08 an application to the Commission for social care Inspection to become the registered manager to ensure that people using the service live in a home that is managed by a person who is fit to be in charge. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP35 Good Practice Recommendations When dealing with the personal money of people using the service, two members of staff sign for all transactions to ensure that this is safeguarded. To carry out staff supervisions at least six times a year to ensure that staff maintain good working practices. OP36 Autumn Grange Care Home DS0000002190.V367444.R03.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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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