Inspection on 03/02/09 for Docking Grange

This inspection was carried out on 3rd February 2009.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Docking Grange 30/12/09

Docking Grange 18/08/08

Docking Grange 21/02/08

Docking Grange 16/10/07

Docking Grange 03/10/06

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 27/03/2009.

CARE HOME ADULTS 18-65 Docking Grange Sandy Lane Docking Kings Lynn Norfolk PE31 8NF Lead Inspector Lella Hudson Unannounced Inspection 3rd February 2009 10:30 Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 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 Docking Grange DS0000066607.V374113.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 Adults 18-65. 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. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Docking Grange Address Sandy Lane Docking Kings Lynn Norfolk PE31 8NF 01485 518428 01485 518436 docking.grange@hotmail.co.uk www.concensusupport.com Caring Homes Healthcare Group Ltd 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) Matthew Dale – not yet registered Care Home 34 Category(ies) of Learning disability (34) registration, with number of places Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Any service user, of either sex, accommodated over the age of 65 must also have a learning disability. Any service user, of either sex, accommodated with dementia must also have a learning disability. 18th August 2008 Date of last inspection Brief Description of the Service: Docking Grange is a private residential care home that provides accommodation for up to 34 residents. The home consists of the original building (Daphnes and The Hollies,) and three modern houses built at the rear of the home (Badgets, Caddows and The Coach House) All bedrooms, are single and most of the bathrooms and shower facilities are suitable for use by residents with a physical disability. Whilst every resident has their own house within the Home and staff are allocated to different areas, the Home is actually run as one. Many of the residents have lived at the Home for many years. The home has pleasant grounds, which are well maintained and accessible for all residents. The Home is in the village of Docking, which is approximately eight miles from the coast and approximately fifteen miles from both Kings Lynn and Fakenham. Docking Grange DS0000066607.V374113.R01.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 ONE STAR. This means that the people who use this service experience ADEQUATE quality outcomes. This report contains information gathered about the Home since the last Inspection (August 2008). It also includes information gathered during an unannounced visit that was carried out by two Inspectors on 3rd February 2009 between 10.30am and 4.50pm. During our visit we spoke to the Manager, staff and residents. We also looked around the Home and looked at a selection of records. The Home has had several managers since the Home was bought by Consensus in 2006 and at the last Inspection (August 2008) it was found that residents experienced poor quality outcomes as a result of the service provided at the Home. We met with the organisation and the new Manager in September 2008 and they provided an improvement plan at that time. The new Manager, Matthew Dale, was appointed in August 2008. He had previously managed another Home within the organisation. During this visit to the Home we saw that a great deal of improvements have taken place and that the quality of life for the residents has improved. The Manager and staff have worked hard to make the improvements and they have received the support and resources from the organisation to do so. The Manager has an ongoing plan of action for further improvements. What the service does well: Some parts of the Home provide homely, comfortable accommodation for small groups of residents to live together. There is an attractive garden which is accessible for all residents. The Home has vehicles to enable the residents to go out as there is little, or no, public transport from the village of Docking. The residents receive meals which are healthy and are attractively presented. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The improvements to the accommodation are ongoing and there are still areas in need of redecoration and refurbishment. The opportunities for residents to take part in meaningful activities needs to be further improved so that residents have a choice about a range of activities that they may wish to take part in. Some of the care plans would benefit from further detail to ensure that the guidance available to staff is clear and consistent. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 7 The staff would benefit from increased training in subjects specific to individual residents needs, such as dementia, epilepsy, communication. The Manager has plans in place to address all of the above issues and other areas in need of improvement. 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. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home has appropriate procedures in place for the admission of residents. EVIDENCE: There have not been any admissions to the Home since the last Inspection. Following the last Inspection report the organisation voluntarily agreed not to admit any further residents until improvements had been made. They are now ready to admit residents again. We discussed the procedure with the Manager and this would include a thorough assessment of the individuals needs and include gathering information about their needs from others involved in their life. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. To ensure that the residents receive care in a consistent way the care plans need to be more detailed. The views of the residents are being sought in a more proactive way. EVIDENCE: We looked at three of the care plans and could see that there has been a lot of improvements made to the care planning process since our last Inspection. The Manager said that all of the care plans and risk assessments have been reviewed and updated. The three care plans that we saw contained a lot more detail than they had previously. They are also being written in a more person centred way. For example, for one resident there is a clear plan about how they should receive support with personal care and it directs the staff to allow the resident to do as much as they can for themselves. Another example is that one of the Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 11 residents has a clear plan in place for the support that they need with regard to their behaviour. This includes information about possible triggers and how staff may be able to use divertion techniques. However, there are other areas where further detail is needed so as to provide clear guidance for staff about how to meet the residents needs. For example, one of the residents uses oxygen and the care plan refers staff to the training that they have had about this but it would be more helpful if the care plan actually contained the information about the care needed. Another resident has asthma but the care plan does not contain information about what signs to look out for and when to give inhalers. There is evidence that regular reviews are taking place but the original plan is not updated which means that staff have to read all of the reviews to ensure that they are getting accurate information. Not all of the records are signed and dated. The Manager is aware that this needs addressing. He also has plans to involve the residents and their representatives more in the care planning process. The risk assessment process has improved and there are now more personalised risk assessments. However, there are still some risks that have been identified but for which there is not clear guidance about how to manage the risks. For example, two of the residents whose care plans we looked at spend all of their time sitting or lying down but there are no risk assessments for pressure sores. There are still some corporate risk assessments which are not personalised or clear enough. Some of the care plans also contain old risk assessments as well as the newer ones which could be confusing to staff. The Home now has four senior staff, including the deputy manager, and they are all responsible for one area of the Home. They take the lead with regard to ensuring that the care plans and risk assessments are reviewed and updated. Staff said that they are involved in discussions about changes to the care plans. Each of the care plans contains a financial care plan but this does not state how much each resident is entitled to. The residents money is paid into a corporate account and then money is provided to each resident as needed. However, this is managed by the organisations Head Office and so the Manager, and therefore the residents, do not know how much each resident is entitled to. We looked at the records relating to one of the residents money and there are clear records kept of expenditure and receipts are obtained. We checked the cash held and this tallied with the records. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 12 The Manager said that he has met with the person who provides training about Communication and that further training is planned for the staff team. He said that the intention will be for some staff to attend the Communication Coordinators training so that they can take the lead with regard to assessing residents communication needs and ensuring that appropriate training is provided to the staff team. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, & 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents receive an appealing diet. The residents are supported to take part in meaningful activities on an irregular basis. EVIDENCE: We spoke to residents and staff about the range of activities that the residents are involved with. We also looked at records relating to this. Residents said that they are able to go out more often. One of the residents said that this depends on the number of staff on duty but that they do go out more. The increased staffing levels are being used in a proactive way and staff are working hard to ensure that residents are offered the opportunity to go our more often. In addition to this some games and craft making equipment has been purchased to use at the Home. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 14 Although residents are going out more often there are still long periods of time when some residents have not gone out of the Home. The Manager said that recording is not taking place of all the activities that are actually happening. Some of the residents attend formal day services during the week but at weekends all of the residents are at home. The Manager said that they do try to have an additional member of care staff on duty at the weekend. The Home is located in a rural village close to the coast. There is a shop and public house in the village which the residents are supported to use on a regular basis. There is no public transport to the village and so the Home has two vehicles. The Manager said that he plans to recruit a part time activity coordinator. The care plans contain information about the dietary needs of the residents and training is provided for staff with regard to those residents who have additional needs at mealtimes. Staff told us that the increased staffing levels have improved the support that residents get at mealtimes as they can now receive one to one support for the length of time that it takes to assist them appropriately. Residents told us that they like their meals and the meal that we saw looked appealing and appetising. The majority of meals are all home cooked. Each area of the Home has a weekly house meeting at which the next weeks menus are planned. Another improvement since the last Inspection is that each area is now responsible for their own shopping and cooking. Residents are supported to go shopping on a weekly basis rather than having food delivered which is what happened previously. A cook is employed five days a week to cook meals at Daphnes so that the care staff can concentrate on supporting the residents. The staff in the other areas of the Home are responsible for cooking meals for the residents who live there. Two of the kitchens in the small houses have been refitted. One has also had a breakfast bar fitted which makes more space in the kitchen and means that the residents can use the breakfast bar for assisting with meal preparation. A new breakfast bar that is height adjustable is going to be fitted into another of the small houses. The kitchen in Daphnes was being refitted at the time of our visit. Following the fire officers visit a new wall has been built in Hollies so that this kitchen can be used for cooking again. Previously the meals had been prepared in Daphnes kitchen as it was not safe to use the kitchen in Hollies due to the kitchen area being too open. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of the residents are met. Medication is managed in a safe way. EVIDENCE: We spoke to staff about the support that residents need. The staff said that the increased staffing levels means that they are able to spend more time with individual residents, particularly when assisting them with personal care. We spoke to social care professionals who also said that they feel that there have been improvements in the care provided to the residents living at the Home. As previously mentioned in this report, the care plans would benefit from further clarity. For example, one of the residents has epilepsy but the care plans for this is not clear about the actions staff should take in the event of a seizure. The care plans contain evidence that residents are supported to see the local GP and District Nurse where appropriate and also to attend appointments with dentists, opticians and chiropodists as needed. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 16 The Manager said that they have started to use the Health Action Plans but they are not in place for all of the residents yet. Some of the residents are becoming more physically frail and so need mobility equipment such as assisted baths/showers and adjustable beds. Alterations to the home have been made where possible and equipment has been purchased to assist residents. The Manager is aware of the need to liase with care managers if the accommodation no longer meets a residents needs. We looked at the system in place for the management of medication. This is kept securely in each area of the Home. Staff receive appropriate training prior to administering medication on their own. The records that we saw were completed appropriately. Staff told us that they have received a lot of training since the last Inspection and there is more planned. The Manager gave us a copy of the training matrix and from this we can see that mandatory training such as moving and handling, first aid and infection control is being provided and that the majority of staff have received this training. Some staff need updates and newer staff are still waiting for this training. The Manager said that training is provided from a variety of sources. The organisation training department maintain the overall training records to ensure that staff all receive mandatory training. The Manager and another member of staff are trained to provide the moving and handling and the safeguarding training. External training providers are used and local health professionals, such as the continence advisor, have provided some information sessions. The Manager has plans for further training about issues relevant to individual residents. Currently the staff work in all areas of the Home although they said that they do tend to work in one area more than others. Discussions with staff show that there are some staff who are not as confident working with all of the residents as other staff. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and action taken to address them. Procedures and staff training are in place to provide protection to the residents from abuse. EVIDENCE: The complaints procedure is on display around the Home in a simple format using words and pictures. Training about communication will assist the staff in being able to understand if residents want to make a complaint about anything as currently those who have communication difficulties would find this extremely difficult. The Manager encourages an atmosphere of openness and honesty and as such he encourages people to raise concerns if there is an issue. He is keeping records of all issues raised, however minor. Two such concerns have been recorded since the last Inspection. The Commission has not received any complaints about the service since the last Inspection. The staff who spoke to us were clear about the need to report any concerns about possible abuse and were confident that the Manager would deal with these appropriately. The records show that there are still staff who need to attend training about Safeguarding but that these are mainly new members of staff. There are dates booked for this training. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 18 Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The quality of the accommodation is mixed, with some areas providing homely and comfortable accommodation, and others in need of improvement. EVIDENCE: Further improvements have been made to the accommodation since the last Inspection. For example, new kitchens have been fitted to two of the small houses and one is being fitted in Daphnes. A new level access shower has been provided in Daphnes. Curtains are finally up at the windows in Daphnes, providing more privacy and making the lounge more homely. The bathroom that had been newly fitted in Daphnes at the time of the last Inspection has now been nicely decorated with pictures and ornaments and is a homely and attractive room for the residents to use. New bedroom furniture has been provided in some bedrooms, including for one of the residents who has been waiting for a long time for new furniture. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 20 However, there are still areas of the Home, that are still in need of redecoration and refurbishment. The Manager agreed to send us an updated maintenance plan after the Inspection. Some areas of the Home are bare and not attractive rooms for the residents to spend time in, particularly the bathrooms and toilet areas. The bath in Hollies bathroom is stained and this is a particularly drab room. One of the residents of Hollies likes to have a bath as a form of relaxation and this room is currently not a pleasant room to be in. We saw toiletries, including razors and combs, left in most bathrooms which would indicate that they are for communal use. The Manager said that he had removed these before we left the Home. There are continence pads on display in most bathroom/toilet areas and bedrooms. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The increase in staffing has led to improved lifestyles for the residents. Staff are now receiving effective supervision and training to carry out their roles effectively. EVIDENCE: The staffing levels have been increased and staff were able to give us clear examples of how this has led to improvements in the lifestyles of the residents. Staff are able to spend more time with individual residents on a 1:1 basis. This is particularly important for those residents who are becoming more frail and therefore needing more support with personal care tasks. Staff said that the residents now rarely have to wait for support on those occasions when they need two staff to support them, such as when using the hoist. The increase in staffing has also meant that staff are able to support residents to take part in activities on a more regular basis than previously. Ongoing recruitment has meant that there are several new staff who have started work at the Home. New staff told us that they have received good Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 22 induction and that the other staff provide good support to them. Staff retention is improving also with less staff having left in the last six months. There is now very little use of agency staff. The staff told us that they receive regular supervision and that they are all due to have an annual appraisal in the next month. They said that there is always a senior member of staff on duty and that the on call system works well in the event of needing advice when the Manager is not on duty. The number of senior care staff has increased to four, including the deputy manager, and their roles have been clarified so that they are now each responsible for a different area of the Home. Staff told us that handovers are now more effective and that there is better organisation and planning of the shift. As already mentioned in this report additional training has been provided to the staff team since the last Inspection and there are further dates planned. The Manager intends to ensure that staff receive training about issues specific to individual residents as well as the mandatory training. We looked at a selection of recruitment files and could see that appropriate checks are carried out prior to staff working at the Home. Staff who spoke to us confirmed this also. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home is well managed in a way which puts the needs of the residents first. Health and safety is taken seriously and issues addressed as they arise. EVIDENCE: Matt Dale started working as the Manager of the Home the week before the last Inspection (August 2008). He has made a lot of improvements in the six months that he has been managing the Home. He has also had the support of the Responsible Individual of the organisation throughout to enable the improvements to go ahead. The Manager has relevant experience and qualifications to manage the Home. He is in the process of applying for registration with the Commission. He undertakes the same training as the care staff and in addition to this has Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 24 attended specific management training and is also due to attend Mental Capacity Act training in March. We spoke to staff, residents and social care professionals about the management of the Home and they were all very positive about the improvements that have been made since the Manager started at the Home. They are also positive about his style of leadership. They said that he has good communication skills and that he puts the needs of the residents first. The Home now has a strengthened management team as there are three senior care staff and the deputy manager. There is always a senior member of staff on duty to provide direction and support to the care staff. On the day of the visit the Home was also having an unannounced quality audit undertaken by the Care Services Manager employed by the organisation. The organisation has used questionnaires to obtain views about the service provided and aim to continue with this. The views of the residents are being sought on a much more regular basis, through staff spending time with residents and through the house meetings. We can see that action is now being taken when issues are raised about the quality of the service. We looked at a selection of Health and Safety records and could see that regular maintenance and servicing of equipment takes place. The Manager could not find the certificates relating to the servicing of the fire safety equipment but confirmed that these have been done. The Home employs someone to be responsible for the maintenance of the building. Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 3 3 X X 3 X Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 Requirement It is required that the care plans provide staff with detailed guidance about how to meet the client’s needs. This requirement had a timescale of 31/10/08 which has not been met. Timescale for action 31/03/09 2. YA9 13 It is required that risks are 31/03/09 identified, assessed and that clear guidance is provided to staff about how to manage the risks This requirement had a timescale of 31/10/08 which has not been met. It is required that staff receive appropriate training to enable them to carry out their roles It is required that the bath in Hollies bathroom is replaced 31/05/09 30/04/09 3. 4. YA35 YA24 18 23 Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA6 YA6 YA7 YA24 YA24 Good Practice Recommendations It is recommended that the care plans are updated when there is a change as a result of a review It is recommended that the old care plans and other ‘out of date’ information is removed from the current files It is recommended that the amount of benefit that each resident is entitled to is recorded It is recommended that communal toiletries are removed It is recommended that there is better storage in the bathrooms/toilets and in some bedrooms Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI Docking Grange DS0000066607.V374113.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!