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Inspection on 04/04/06 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 4th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

The registered manager is open and will listen to suggestions and will seek advice to improve the quality of the lives of residents in the home. Where the review officer has offered the new care plan format the manager is keen to use this to improve care plans. The manager has introduced residents meetings enabling residents to be part of the home and decision making process. Where the manager has concerns she will contact the Commission to ensure that residents are not placed at risk. All the residents said that their personal space was kept clean.

What has improved since the last inspection?

The requirements set regarding the poor maintenance in some areas have been met to the Environmental Health Officers satisfaction. Staff have received their Fire Awareness Training. The difficulties with the heating system and poor hot water supply to Unit 3 appear to have been resolved and on the day of the inspection were found to be in working order. The manager has started running regular residents meetings and there was some improvement in resident involvement in decision-making and some improvement in the amount of activities offered particularly in Unit 3.

What the care home could do better:

The registered manager is striving to improve the care plans, but the formats used in the past have hampered any improvement. Staff must witness residents taking medication before signing the Medication Administration sheet. This practice potentially places residents at risk. The registered person must ensure appropriate action is taken to minimise risk. Although residents meetings are now taking place and residents are being asked about activities, generally there is still a lack of activities. An incident occurred where the procedures for complaints was not followed appropriately by a member of staff and a complainant was asked to put their complaint in writing before it could be dealt with. The registered manager must ensure that that all staff are aware and follow procedures fully. Staff need training on working with people challenging behaviour to reduce instances of inappropriate exchanges in communication. The Registered Person must develop a quality system, which highlights deficiencies in the environment, services and facilities such as bedding, heating, infection control etc.

CARE HOMES FOR OLDER PEOPLE Autumn Grange Care Home 19-29 Herbert Road Sherwood Rise Nottingham NG5 1BS Lead Inspector Susan Lewis Unannounced Inspection 4th April 2006 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.V288234.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.V288234.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.V288234.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. 10th November 2005 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 been reconfigured, with an enclosed safe garden being created 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.V288234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of the new inspection year 2006/07; it was unannounced and was carried out by one inspector over 7 ½ hours. The inspection also used evidence provided prior to the inspection from various sources including the Review Officer from Nottingham City Council and complaints received. A partial tour of the building took place and a selection of residents bedrooms were viewed. Seven residents care records were viewed and staff training records were inspected. Residents, visitors and staff were spoken with during the course of the inspection. The registered manager was present throughout the inspection, though the registered provider was unavailable. What the service does well: What has improved since the last inspection? The requirements set regarding the poor maintenance in some areas have been met to the Environmental Health Officers satisfaction. Staff have received their Fire Awareness Training. The difficulties with the heating system and poor hot water supply to Unit 3 appear to have been resolved and on the day of the inspection were found to be in working order. The manager has started running regular residents meetings and there was some improvement in resident involvement in decision-making and some improvement in the amount of activities offered particularly in Unit 3. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 6 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. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 7 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.V288234.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 The quality in this outcome area is poor. Assessments carried out by the home are not always clear and do not always provide sufficient information to create an appropriate care plan to ensure that residents know how their needs are met when they enter the home. This potentially places residents at risk. EVIDENCE: Seven care plans were viewed for the purpose of this inspection. All plans viewed contained an extended community care assessment from a social worker and an assessment carried out by a senior member of staff at the home. This provided basic information to create a care plan from. However this information is not clearly defined and can appear confusing as to whether the information is an assessment or a care plan. Where residents require specialist services such as residents with dementia it was not always clear what the service was or who should provide it. The review officer’s report also raised concerns regarding the clarity of care plans and the assessments in the summary of the review carried out in the home between February and March 2006. The home provides a service to a number of residents from different ethnic backgrounds; in some cases providing appropriate meals and services, where residents do not want their cultural needs met this should be recorded on their care plan. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 The quality in this outcome area is poor. Residents are not always well looked after in respect of their personal care needs, care plans lack clarity and their health, personal and social health care needs are not set out in a plan of care in detail. Inconsistent care practices prevail for medication administration and health care and are not protected by procedures for dealing with medicines. EVIDENCE: A requirement was set at the last inspection regarding writing care plans in more detail. This process has started, but the actual style of plan is confusing and it is not always clear what care a resident actually needs to maintain their well-being particularly where a behaviour that could harm a resident is involved. This was referenced in the summary of the review from Nottingham City Council. In discussion with the manager and later confirmed by the review officer, a format will be provided to the manager to follow and use as a template for all care plans. This requirement is not fully met and as this has been an outstanding requirement since 30/09/05 an immediate requirement is issued. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 10 Residents spoken with said that staff sometimes sat with them to go through the care plan and visitors spoken with on the day also confirmed that they had been involved with the initial creation of the plan. Staff spoken with said that they would create a care plan with residents and/or family members if the resident were not able to participate. This was not clearly evidenced on care plans nor was any further involvement the resident may have. Care plans showed that residents were regularly weighed however it was not always clear what action was taken if a residents weight changed significantly. Reading care plans and looking at daily diary notes it was not always clear what care residents were receiving and what follow up action was being taken where concerns had been expressed. The registered person must ensure that where concerns have been expressed regarding a residents behaviour, possible ill-health or anything that may affect the residents well being that follow up action is taken and documented. It was evident that appropriate action was taken where residents either came into the home from hospital with a pressure sore or developed one in the home. Evidence was seen that incontinence was monitored and again the appropriate person was contacted to provide support to meet that need. Evidence was seen of regular chiropodist treatment being carried out as well eyesight and dental treatment. Staff spoken with understood the importance of specialist eye care for the residents who had diabetes. Five requirements were made at the last inspection regarding medication. 1. Appropriate arrangements must be made to ensure that prescriptions are picked up in time to take to the pharmacist. The manager provided evidence to show that the home has now changed its contract from the previous pharmacist to a new provider and the issue regarding late prescriptions is resolved. This requirement is met. 2. The Registered Person must ensure that medicine record sheets are appropriately signed and witnessed when hand written. There was no evidence that any of the medication sheets were hand written and therefore this requirement is met. 3. Staff must not give medication to residents covertly. This was discussed with manager and she had spoken with the individual concerned Community Psychiatric Nursed who advised her to look at www.ukcc web site to obtain definitive advise regarding this subject. The registered manager should ensure that appropriate action is taken according to this good practice advice. This requirement will be made into a recommendation following this discussion. 4. The fridge temperature must be recorded to ensure it is operating within safe margins. Evidence was seen that temperatures were being taken regularly and it was working within safe limits to ensure that medication was being stored safely. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 11 5. It must be clear on all medication who the medication is intended for. If liquid medication is prescribed, prescription details must not be separated from the bottle. A random sample of bottles and inhalers were checked and all had the appropriate label saying whom the medication was intended for, ensuring residents only receive the medication intended for them. Whilst discussing complainants concerns regarding the care of a relative in the home, the complainant reported that staff had walked into the residents room placed a tablet on the table and walked out again without checking the resident had taken the medication. A number of tablets had previously been found in the resident’s pocket. This had been brought to the manager’s attention who was clearly aware of this practice. Residents spoken with also confirmed that this practice took place. This is unsafe and staff must ensure that they witness a resident take a tablet before signing the Medication Administration Record. The registered manager must ensure that medication is only administered according to the home’s procedures and guidelines from the Royal Pharmaceutical Society. Residents spoken with confirmed that staff treated them with dignity and respect. This was also supported by the reviewing officers report. The majority of the visitors spoken with confirmed saying ‘I can’t find fault with the staff, they are very good and exceptionally caring’. It was noted during the inspection that at least six of residents were observed to be dirty, food from the mid day meal was on their clothes and around their face. They appeared dishevelled, their hair unbrushed and with a general air of neglect. Two particular residents observed were raised with the registered manager, who was aware of the residents involved. The manager said that this was in their care plan. Staff spoken with were aware of how care should be provided and how to support residents privacy and dignity, residents spoken with confirmed that they received personal care in their bedrooms or the bathroom. Those care plans looked at provided evidence that resident’s wishes regarding death and dying are identified; this was also noted in the review officer’s report. The review officer recommended that where an advocate is required that this be evidenced in the care plan. This recommendation is also made in this report. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 The quality in this outcome area is adequate. Residents are assisted to exercise choice and control over their lives, and are offered a balanced diet in line with dietary requirements. Residents do not always find the lifestyle experience in the home matches their expectations and preferences. Limited funding by the registered provider limits the choice of activities within the home. EVIDENCE: Evidence was received from the residents meeting minutes, the reviewing officer’s report, residents and visitors that activities and stimulation within the home was poor. However the meeting minutes provided evidence that attempts were being made to try to address this issue. In discussion with staff it was clear that ideas such as raffles and car boot sales were being used to try to raise funds to do activities. The manager reported that these ideas were to raise funds in addition to existing funding. Residents spoken with confirmed that they did not do much during the day. Funding must be made available to ensure appropriate activities are provided for all residents ensuring residents with dementia have suitable activities to meet their needs. As this is a quality issue this will be passed to the Commissioners of this service to follow up regarding the contract they have with the provider. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 13 The home must also make arrangements where possible for residents to maintain links with their old community such as attending their old church if requested, if transport is arranged and then the resident refuses this should be recorded. Residents spoken with said that they could do what they wanted, and felt they could exercise some control over their lives and some residents were observed retiring to their bedrooms at various times during the day. Care plans detailed what time a resident liked to go to bed and what time they liked to get up. Visitors spoken with who said they visited at different times during the day confirmed that if they visited in the evening their relatives were not in bed. Although the main meal of the day was not observed on this occasion, residents spoken with said that the food was ‘fine’ or ‘ok’. The residents meeting minutes showed that there had been issues regarding the quality, quantity and temperature of the meals, this in January 2006, however subsequent minutes showed that this had been addressed and residents all confirmed this. A visitor had raised concerns with the inspector that there were occasions where residents did not get drinks during the afternoon and so there was a risk of dehydration. Although other visitors or residents did not confirm this, the registered manager must ensure that throughout the home residents receive regular drinks and snacks during the day and evening and a recommendation is made accordingly. A menu was seen in each of the dining rooms detailing what the choice was for that day; ensuring residents could make an informed choice or ask for an alternative if they so wished. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is poor. Procedures are not always followed to ensure complaints are dealt with appropriately and there is potential for residents not to be protected from abuse where staff have not received appropriate training or supervision regarding working with residents with challenging behaviour. EVIDENCE: Although the majority of residents and visitors spoken with felt confident that their complaints would be dealt with. It was evidenced that a complaint made by a relative had not been handled appropriately. In a letter received by the Commission it reported that the deputy manager had asked the complainant to put in writing the complaint. This is unnecessary and complainants should not have to put anything writing it is for the staff to follow policy and procedure and deal with a complaint accordingly. The complainant had raised an issue regarding inappropriate use of a resident’s property. Evidence was seen that the manager had spoken to the member of staff involved and also advised all staff against similar behaviour. The manager must ensure that all complaints are recorded as such and dealt with appropriately. Residents spoken with said that they felt safe in the home and that staff were ‘fine’ and spoke appropriately to them. However, two visitors said that they had on occasions heard staff snap at residents, but could not identify which staff or which resident. This was discussed with manager on the day and gave examples where staff may have appeared to speak sharply but it was to prevent residents assaulting another resident. The manager must ensure that all staff are made aware of what constitutes abuse and ensure all staff who work in areas where residents have challenging behaviour have appropriate training to be able to carry out this work. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 The quality in this outcome area is poor. The home is poorly maintained and poor hygiene practice places residents at risk. EVIDENCE: At the last inspection on 11/11/05, which was carried out with the Environmental Health Officer (EHO) a number of concerns were raised regarding the poor state of repair in some areas of the home. These have been resolved to the EHO’s satisfaction at his follow up visit. Concern is raised regarding the environment by evidence provided by a complainant and the review officer’s report. Photographic evidence was provided of the poor state of residents’ chairs, they were dirty and in one case smeared in faeces. Chairs in the lounges of all three units were in a poor state of repair and in some cases not suitable for the needs of the residents. An example of this would be, chairs with wooden arms making it uncomfortable for residents to sit for very long. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 16 All residents and relatives spoken with confirmed that the bedrooms were kept clean, however bedrooms viewed had shabby bed linen and in a number of bedrooms the quilt was thin and lumpy, the pillow stained and lumpy. In a number of cases the beds had not been made as they were without pillow case covers or bottom sheets. Recently the home has experienced a protracted period where the heating system was not working and hot water was unavailable in certain parts of the home, although this has now been resolved it is symptomatic of the poor maintenance in the home in general. This is a large home with a number of residents with challenging behaviour, therefore signs can be pulled off the wall and other damage may occur on a regular basis. It would therefore be beneficial for the registered person to employ a handy man, so the manager can have small items dealt with quickly and efficiently. The reviewing officer’s report made mention that a bath had been used as a sluice and faeces was seen in the bath itself and later when cleaned still in the drainage area. This is poor practice and may lead to cross infection. The registered manager must ensure that appropriate action is taken to stop this happening again. This was challenged by the manager as being incorrect and that she discussed this with the reviewing officer at the time, however when the inspector followed this up with the reviewing officer, the reviewing officer confirmed that the manager had alleged it was ‘residue from a ceiling that had been poured into the bath by a cleaner’. However the reviewing officer and the colleague with her at the time challenged this, they informed the manager that it was clearly faeces; the manager did not dispute this with reviewing officer. A requirement was made at the last inspection regarding screens in shared bedrooms residents spoken with who shared confirmed that screening was available. This requirement is now met. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 The quality in this outcome area is poor. It is not clear that sufficient staff are employed to meet the needs of residents. Lack of a training programme and budget has the potential to place residents at risk. EVIDENCE: Several cleaning staff were in evidence throughout the day as well as a laundry assistant and cook. During the course of the day although all three units were fully staffed they were constantly busy and did not appear to spend time talking to residents. Residents spoken with said that sometimes it was difficult to get a carers’ attention to help them if they wanted to go to their bedroom or toilet. Residents spoken with said that they were told to wait a few minutes and it would be much later that they were seen to. The registered person must establish that staff are employed in sufficient numbers to meet the dependency needs of residents. On the day of the inspection evidence was seen that Fire Awareness training was taking place for all staff working at the home and lists of training courses for staff to attend were around the office. Staff spoken with said that they understood that most of the training accessed on their behalf by the manager was free or the charge could be reimbursed. 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. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38 The quality in this outcome area is adequate. It is not always evident that the home is run in the best interest of residents. The home is poorly maintained care records are not well recorded. Residents benefit from a staff group that are supported through regular supervision but are placed at risk by lack of clear budgeting. EVIDENCE: The manager must ensure that a clear connection between the monitoring chart and action taken must be made in care plans to ensure that appropriate action has been taken and all relevant professionals have been involved. Both staff and residents spoken with said that they found the registered manager approachable and very supportive. A member of staff said that the manager had been supportive whilst she did her NVQ and helped her look at her development during supervision. Although the residents and staff find the manager approachable the evidence from the Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 19 inspection is that the standards where the manager should be ensuring residents safety and well-being are not being sufficiently monitored to ensure residents safety. A requirement was made at the last inspection for the registered person to establish an effective quality assurance system. An external quality organisation was brought in to advise on improving practice a copy of this report was sent to the Commission. From this report the registered manager has now established regular residents’ meeting, which enables residents and relatives to be involved in decision making within the home. Regular staff meetings have also been established. The quality questionnaire is still to be developed. The home has suitable insurance to protect residents should this be necessary. The registered manager was asked to show a business plan for 2006/07 and was unable to provide this. Due to the poor state of repairs in the home the apparent lack of training budget the registered person is required to provide a copy of the business and financial plan for the establishment to ensure that residents are benefiting from a well run home. In the review officers report it showed that the home had a pooled account for residents finances. The reviewing officer evidenced that this practice stopped and appropriate alternative measures were taken to safeguard the residents’ monies. Staff receive regular supervision where practice issues are discussed these are all recorded and evidence was seen that this takes place this ensures that residents benefit from appropriately supervised staff. At the last inspection 11/11/05 the inspector had been unable to access a number of files necessary to carry out the inspection as the office was locked and the manager was unavailable. This no longer happens and suitable arrangements have been made to ensure that records are available. This requirement is met. Some residents spoken with were aware that the home kept a care plan about them but not all. Most residents were not aware that they could access them whenever they wanted to. The registered manager must ensure that arrangements are made to enable residents to access their records. A full inspection of safe working practices in building was not carried out during this inspection, however a requirement was set at the last inspection to ensure that accident records are stored according to the Data Protection Act 1998. Evidence was seen that this is now done and accidents records are now stored separately from the main accident book ensuring residents information is not accessible to just anyone. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X X X 1 X 1 STAFFING Standard No Score 27 2 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 2 3 3 2 3 Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 21 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 OP3 Regulation 15(1) Requirement Timescale for action 01/06/06 2 OP4 12(1)(a) 3 OP4 4(b) The Registered Person must ensure that the assessments are clear and defined as a separate document from the care plan. The Registered Person must 01/06/06 ensure where residents have specific care needs linked to their dementia this needs to be clearly defined and reference made to what other agencies are involved in the plan. The Registered Person shall 01/06/06 make suitable arrangements to ensure that the care home is conducted with due regard to the sex, religious persuasion, racial origin, and cultural and linguistic background and any disability of service users. Where a resident is from a particular ethnic background or religious persuasion but chooses not to have those needs met it should be detailed in the individuals care plan. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 22 4 OP7 15(1) 5. OP7 15(1) 6 OP8 14(2)(a) (b) 7 OP9 13(2) The Registered Person should ensure that each service user has a written plan as to how the service users needs in respect of his health and welfare are to be met. The identified plans should be written in more detail. (Outstanding Requirement 30/09/05) This is now an immediate requirement The Registered Person should ensure that each service user has a written plan as to how the service users needs in respect of his health and welfare are to be met. The manager will ensure the care plans are clear and define residents assessed needs. The Registered Person shall ensure that the assessment of the service user’s needs is kept under review and revised at any time when necessary to do so having regard to any change of circumstances. Where residents weight changes significantly then any action taken must be recorded effectively within the care plan. Registered Person shall make arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. Staff must ensure that residents are witnessed taking their medication prior to signing the Medication Administration Record Sheet, or a risk assessment is carried out to say they are safe to self medicate. 01/05/06 01/05/06 01/06/06 01/06/06 Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 23 8 OP12 16(3) 9 OP16 22(1) 10 OP18 13(6) 11 OP19 13(4) 23(2)(b) (o) The Registered Person shall ensure that so far as practicable service users have the opportunity to attend religious services of their choice. Where service users have expressed a wish to attend their local church arrangements should be made and a record made on their care plan if they decide not to go. The Registered Person shall establish a complaints procedure for considering complaints made to the registered person by a service user or a person acting on the service users behalf. Complainants must not be told that they have to put their complaints in writing. The Registered Person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Where staff work with residents with challenging behaviour they should receive appropriate training to support them. The Registered Person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. The registered person must ensure that all identified hazards created by poor maintenance are corrected. 01/08/06 01/06/06 01/06/06 01/06/06 Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 24 12 OP19 13(4) 13 OP24 16(2)(c) 14 OP26 13(3) 15 OP27 18(1) The Registered Person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. A programme of routine maintenance and renewal of the fabric and decoration of the premises must be produced and implemented with records kept. The Registered Person shall provide in rooms occupied by service users adequate furniture, bedding and other furnishings, including floor coverings and equipment suitable to the needs of service users. New bedding must be provided for all residents where it has become thin, lumpy and stained. New chairs must be bought where they have become unsuitable for the needs of the resident, stained and dirty. The Registered Person shall make arrangements to prevent infection, toxic conditions and the spread of infection at the care home. Baths must not be used as sluices. The Registered Person must ensure staff are employed in sufficient numbers to meet the dependency needs of residents. 01/07/06 01/06/06 01/05/06 01/04/06 Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 25 16 OP33 24 The registered person shall 01/08/06 maintain the quality assurance system that reviews and improves the quality of care at the care home, and supply the Commission with a reporting respect of any review and make a copy of the report available to service users. Evidence was seen that work has started on this and although not fully met enough has been done to extend the date. (Outstanding Requirement 31/07/05) The Registered Person shall carry 01/06/06 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. The Registered Person shall 01/08/06 make the service user’s plan available to the service user. Ensure that all service users are able to access their care plan and record where they have declined the opportunity. 17 OP34 25(1) 18 OP37 15(2) Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 26 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 OP19 OP30 Good Practice Recommendations Recommended that where an advocate is required that this be evidenced in the care plan. It is recommended that the Registered Person employ a maintenance person. 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. Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Autumn Grange Care Home DS0000002190.V288234.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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