Inspection on 03/08/09 for Christopher Grange (Rhona House)

This inspection was carried out on 3rd August 2009.

CQC 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 CQC 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

Christopher Grange (Rhona House) 02/08/07

Christopher Grange (Rhona House) 31/08/06

Christopher Grange (Rhona House) 02/03/06

Christopher Grange (Rhona House) 21/10/05

Christopher Grange (Rhona House) 04/12/04

Similar services:

SignHealth

Mere Hall View

Beechfield Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Christopher Grange (Rhona House) Youens Way East Prescot Road Liverpool Merseyside L14 2EW Lead Inspector Jeanette Fielding Key Unannounced Inspection 3rd August 2009 10:20 DS0000025095.V377187.R01.S.do c Version 5.2 Page 1 DS0000025095.V377187.R01.S.do c Version 5.2 Page 2 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 3 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Name of service Christopher Grange (Rhona House) Address Youens Way East Prescot Road Liverpool Merseyside L14 2EW 0151 220 25 0151 220 1972 angelaprice@christophergrange.org 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) The Catholic Blind Institute Ms Andrea Lily Madden Care Home 28 Category(ies) of Sensory impairment (28) registration, with number of places Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 5 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate five persons aged over 50 years for nursing care. The home may accommodate one named person aged over 50 years for nursing care. The home may accommodate one named person aged under 50 years for nursing care. 2nd August 2007 Date of last inspection Brief Description of the Service: Rhona House is part of the main Christopher Grange Home, but is registered separately. Rhona House is currently registered to provide nursing care for elderly persons who have a sensory impairment. A total of 28 beds are available, with five of these being available for the care of terminal illness. The home forms part of the Christopher Grange Home that was purpose built for providing services to visually handicapped people and provides all facilities on the ground floor thereby providing full access to all areas. It is situated in Liverpool 14, close to local shops and amenities. The home is set within a residential area, close to shops and major transport routes. The home is owned by the Catholic Blind Institute and has its own chapel in which a daily mass is held. However, residents are accepted from any faith and local ministers of other religions visit to provide pastoral support. Weekly fees at the home range between £436.30 and £700 per week depending on the level of care required. Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 6 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. This inspection was conducted on two days over a period of eleven and a half hours. This was the key unannounced inspection and was carried out as part of the regulatory process. As part of the inspection process, all areas of the home were viewed including many of the service users’ bedrooms. Assessments and care plans were inspected together with staff records and certification to ensure that health and safety legislation was complied with. Discussion took place with a representative of the owner, the registered manager, nurses, care staff, service users and visitors to the home. The manager completed an Annual Quality Assurance Assessment document to give further insight into the home and the service provided. What the service does well: The home employs a qualified and experienced manager who is supported by a well trained staff team. The manager is supported by senior manager and trustees from Christopher Grange and the Catholic Blind Institute. Health and safety issues are well managed to ensure that service users, staff and visitors to the home are protected. A choice of meals is available for service users with special diets and individual preferences being provided. What has improved since the last inspection? What they could do better: The assessment of service users requires to be detailed to include all health, care and social needs to enable the home to confirm that those needs can be met. Care plans require to be detailed and provide staff with full information about how the assessed level of care is to be provided. Attention is required to the recording of medications to ensure the safety and protection of service users. A programme of activities should be prepared following a survey of Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 7 service user’s preferences and abilities to promote social interaction and stimulation. Menus should be displayed in the home to inform service users of the meals available and to remind them of the choices they have made. Cleaning schedules should be prepared for the kitchen within Rhona House. Systems to ensure that there is no malodour from seat covers in the lounge should be put in place. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Christopher Grange (Rhona House) DS0000025095.V377187.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 Christopher Grange (Rhona House) DS0000025095.V377187.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Insufficient information is gathered at the time of the initial assessment to identify service user’s specific needs to confirm that those needs can be met. EVIDENCE: The home has produced a brochure which gives details of the services and facilities within Christopher Grange and also includes the nursing care unit, Rhona House. A statement of purpose and service user guide have also been produced. These documents are currently being reviewed and updated to reflect changes that have recently been made in respect of the management of the unit together with the improvements in service and facilities. Prospective service users and their relatives are provided with information about the home Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 10 to enable them to make an informed decision about their care provider. Additional copies are available from the home on request. The care files of service users recently admitted to the home were inspected to evaluate the information recorded in the pre-admission assessment. The acting manager or one of the qualified nurses undertakes the preadmission assessment. Information is gathered from the service user, their relatives and any other person involved in their care. One care file did not contain a completed pre-admission assessment. The pre admission assessment for two service users did not contain full information regarding the service user’s specific needs. The home is therefore not able, at the time of the admission, to confirm that they are able to meet the service user’s needs and preferences. Discussion with the acting manager, and the newly appointed clinical lead, confirmed that the documentation used and the assessment process are being reviewed to ensure that full assessments are undertaken on all prospective service users. The home also provides specialist nursing care to service users who require care due to their terminal illness. Some of these service users have their assessment undertaken by the District Nurse, District Nurse Liaison, Marie Curie or Macmillan nurses. Documentation produced by these professional is held in the home. The home does not offer intermediate care. Christopher Grange (Rhona House) DS0000025095.V377187.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care files do not contain sufficient information to enable staff to meet the specific needs and preferences of the service users. Medications are not dealt with appropriately which has the potential for placing service users at risk. EVIDENCE: Individual care plans are prepared for each service user. The care files for three service users were inspected to evaluate the level of care required and to identify the actual care given by the staff. One file did not contain sufficient information for staff to enable the appropriate level of care to be provided. Little information was recorded regarding specialist feeding and no information was recorded regarding personal hygiene. No communication plan had been prepared and the lack of information regarding moving and handling had the potential for placing the service user at risk. The acting manager stated that Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 12 the member of staff with responsibility for completing the plan had failed to do so and would be spoken to regarding this. Other staff should take responsibility for completing plans where it is evident that care has not been recorded or is inadequate. Two other files inspected provided information regarding the level of care required. In these files, information was recorded regarding the level of care required and information for staff on how this care was to be given. Risk assessments had been undertaken and risk management plans put in place to reduce any identified risks. The home provides palliative care for up to five service users and strong links have been forged with the PCT, Marie-Curie and Jospice. The home is supported by local GP’s. Additional staff training is given to ensure that both nurses and care staff have the skills and abilities to care for service users who are accommodated for palliative care. Little evidence was seen on the care files to indicate that the service users and/or their relatives have been involved in the preparation and review of care plans. Signatures to provide evidence of involvement should be obtained. Records are maintained of visits to and by GP’s and other healthcare professionals. The clinical lead has been given responsibility for reviewing and updating the care files for all service users and was able to demonstrate that work on this had commenced, using different documentation for recording the information. Daily records are completed by the staff and provided evidence of the actual care given. The policy and procedure for dealing with medications could not be found on during the inspection. These should be rewritten and a copy issued to all staff who deal with medications to ensure that service users are protected. Some blank spaces were found on the Medication Administration Record (MAR) sheets. Handwritten entries on the MAR’s should be signed by two persons to ensure accuracy of the entry. The amount of medication received by the home should be recorded on the MAR together with the amount of medication carried forward from the previous month to enable an audit of the medication to be undertaken. Protocols need to be prepared for service users who are prescribed medications on a when needed (PRN) basis and are unable to request these medications. A record of creams and lotions applied needs to be maintained. Audits on medications were sporadic and have failed to identify shortfalls in record keeping. Regular audits should be undertaken and appropriate action taken where necessary. The medication room has been refurbished since the last inspection and all areas were clean. Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 13 All service users are accommodated in single bedrooms. Care is provided in their bedrooms or in the bathroom as appropriate to protect privacy and dignity. Christopher Grange (Rhona House) DS0000025095.V377187.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a lack of provision of social activities which results in service users not having the opportunity to participate in stimulating or meaningful activities of their choice. EVIDENCE: Christopher Grange employs an activities coordinator but only six hours each week are provided for Rhona House. A singer/entertainer visit the home several times each year but only those service users who are able to attend one of the other units on the site can attend. One service user spoken to said that there was nothing to do that she could participate in. She was unable to read or watch television due to failing eyesight and was generally bored. No records are held of activities that service users participate in. The home has an adapted minibus which can be used by service users for trips, although one service user said that they had never been out. Staff confirmed that they try Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 15 to provide stimulation and activities for the service users but said that they had little time to do this. Within Christopher Grange, a WRVS shop is open five days each week to enable service users to purchase toiletries and sweets. The hairdressing salon within the home is open five days each week but no arrangements are in place for hairdressing to be provided for those who are unable to visit the salon. One service user spends time with friends and relatives in the ‘Market Place’ area of the home where seating is provided within a pleasant area. Rhona House provides a visitors room, ‘Kelly’s Room’ where service users can meet with their relatives and friends. Drink making facilities are provided in this room and access to the garden is available via the patio doors. Mass is held every day in the Chapel for those who wish to attend and services can be provided in service users rooms. A Religious Community live on the site and provide spiritual/pastoral care for service users who request this. A pleasant and secure garden area is provided where service users can spend time as they wish. Meals are served in the dining room, the lounge or in the service users own bedroom as appropriate or on request. No menus were displayed and one service user said that the meals were good, but they could not remember what meal they had ordered. Meals are prepared in the main kitchen and are served from heated trolleys. Rhona House has a kitchen where snacks and drinks can be prepared. On the first day of the inspection, areas within this kitchen were found to be dirty. Drawers contained evidence of food debris and spilled liquids. Cupboards were not clean and the refrigerator was damaged. This was pointed out to the acting manager who arranged for the kitchen to be thoroughly cleaned. A cleaning schedule for this kitchen should be prepared and a record held of cleaning work completed. A choice of meals is offered to service users and the menu seen provided evidence that a varied and balanced diet is offered. Special diets can be provided on the advice of the GP, dietician or at the service users request. The dining room is decorated to a good standard but the room is stark and impersonal. Visitors are welcome at the home at any time and service users can meet with their visitors in one of the communal areas, in the privacy of their own bedroom, in Kelly’s Room or in one of the seating areas around the home. Christopher Grange (Rhona House) DS0000025095.V377187.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have a good knowledge of Adult Protection issues to protect service users from harm or abuse. EVIDENCE: The home has a policy and procedure for dealing with complaints. No complaints have been made to the home in the last twelve months. Information on how to make a complaint is displayed in the foyer and is detailed in the Service User Guide. Service users spoken to said that they would speak to one of the nurses or to their own relatives if they had any concerns. All staff in the home have been given training on the Protection of Vulnerable Adults, the action to be taken in the event of it being suspected and of the home’s whistleblowing policy. This training takes a full day and regular update training is given to the staff. Staff spoken to confirmed that they had been given training on the protection of vulnerable adults during their induction, and had completed the one day training. Staff were able to demonstrate that they were aware of the action to be taken and of the people to whom allegations or Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 17 suspicions would be reported to. Evidence of training undertaken by staff is held on their personnel file. Christopher Grange (Rhona House) DS0000025095.V377187.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Investment in the home has improved the environment to give a more pleasant place for service users to live. EVIDENCE: Rhona House is one of the care units within Christopher Grange. All bedrooms, services and facilities are provided on a single level and gives full access to people who have mobility difficulties or require the use of a wheelchair. A programme of redecoration and refurbishment of Rhona House is now well underway. All areas of the home have been redecorated including bedrooms, Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 19 corridors and communal areas. New carpets have been fitted and new windows installed. All service users are accommodated in single bedrooms and efforts have been made to personalise the rooms with pictures, photographs and items of memorabilia. New furniture has been provided in bedrooms and now provides a more homely environment for service users. The lounge comprises of a large room with a smaller alcove room. These rooms have been redecorated and some new furniture provided. One of the bathrooms has been replaced with a ‘wet room’ to provide a walk in shower. A shower chair has been provided for service users who are unable to stand to take a shower. The tiles in the bathroom by the lounge have come away from the wall and require replacement. There is a lack of orientation signage around the home to assist service users to identify their own bedrooms, toilets and bathrooms. A courtyard garden is easily accessed from Rhona House and is a secure and pleasant area for service users to spend time during warmer weather. The area is protected from the wind and has seating areas. Service users’ bedrooms were clean and fresh but regular attention needs to be given to the laundering of lounge seat covers on a more regular basis as some were noted to be malodorous at the time of the inspection. This was raised with the acting manager and appropriate action was immediately taken. Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a robust recruitment policy and procedure to ensure that service users are protected. EVIDENCE: The home has a robust recruitment policy and procedure and inspection of staff personnel files showed that these had been followed. Prospective staff are required to complete an application form prior to being called for interview. Two references are taken and checks are made through the Criminal Records and Protection of Vulnerable Adults bureaux. Induction training is given to all new staff and evidence of this is held on their files. A sample of staff files were inspected and all were found to contain the required documentation. A new ‘clinical lead’ post has been established and a suitable member of staff appointed. The home employs qualified nurses and care assistants to provide care to the service users. Christopher Grange employs catering, domestic, laundry, administrative and maintenance staff who are all involved in the running of Rhona House. Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 21 Training is given to all staff within the home. Nurses and care assistants in Rhona House are given training appropriate to their role and the needs of the service users. The majority of care staff within the home either hold or are working towards NVQ qualifications. Four staff are currently working towards NVQ at level 4. A matrix has been prepared to identify the training needs of the staff to enable forward planning to be effective. Recent training includes the protection of vulnerable adults, health and safety, moving and handling, medications and wound care. Care staff who work on the night shift would benefit from medications training as they are required to witness controlled medications during their shift. This should be evidenced on their training file. Job descriptions are currently being rewritten by the senior management of the home to ensure that staff roles are clear and to promote a high level of care. Arrangements are now in place to provide regular staff supervision and appraisals. Staff meetings are held to provide a forum for open discussion and the dissemination of information. Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has a good understanding of where the home needs to improve and has identified how these improvements will be resourced and managed to ensure that service users enjoy a good quality of life. EVIDENCE: The registered manager of Rhona House is a qualified nurse who is experienced in the management of care services. She has continued to develop her knowledge and understanding through continued training and is now studying for her NVQ in management at level 4. The manager is working Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 23 closely with the Clinical Lead to address shortfalls within service provision and has set targets and timescales for these. The manager is well supported by the Director of Services for Christopher Grange and by the board of trustees for the Catholic Blind Institute, the owner of the home. Rhona House has recently provided a comments/suggestions book for service users and visitors but no entries have yet been made in the book. Satisfaction questionnaires are distributed to service users and relatives on a regular basis and the information obtained is used to improve the service provision. Some service users’ deal with their own finances and several have their finances dealt with by family members or advocates. Where the home is banking larger amounts of money detailed transactions are maintained and interest is allocated according to the level of savings for each resident. The accounts are audited on a regular basis by the finance director. All records inspected were found to be well maintained and up to date. Fire equipment checks are made on a regular basis as required and duly recorded. Records are also held of fire drills and of the staff involved. Risk assessments are undertaken on equipment, staff and service users and risk management strategies were seen to be in place as appropriate. Safety certificates are held and all were found to be up to date. The home employs maintenance staff on a full time basis to ensure that health and safety issues are identified and dealt with as soon as they are identified. Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 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 3 3 X 3 3 X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Timescale for action 27/09/09 2 OP7 15 3 OP9 13 4 OP12 16 New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party to ensure that the home can meet their identified needs and preferences. Care plans must contain full 27/09/09 information as to how the service user’s needs in respect of his health and welfare are to be met and to ensure staff are made aware of these to enable them to provide the appropriate level of care and support. The registered person ensures 27/09/09 that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines. Arrangements should be made to 27/09/09 ensure that service users are enabled to engage in local, social and community activities and a DS0000025095.V377187.R01.S.doc Version 5.2 Christopher Grange (Rhona House) Page 26 5 OP26 16 6 OP26 16 programme of stimulating activities prepared.27/09/09 Arrangements are to be made to 27/09/09 ensure that the kitchen on Rhona House is maintained in a clean condition. Systems to prevent malodour in 27/09/09 the lounge should be put in place, particularly in relation to the seat covers. 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 OP9 OP12 OP15 Good Practice Recommendations Audits of medications should be undertaken on a regular basis to identify shortfalls in practice. Service users’ individual social preferences should be identified to enable a programme of activities to be prepared. Menus should be provided for service users to refer to and to act as a reminder of the meal ordered. Christopher Grange (Rhona House) DS0000025095.V377187.R01.S.doc Version 5.2 Page 27 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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