Inspection on 03/10/06 for Docking Grange

This inspection was carried out on 3rd October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 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 03/02/09

Docking Grange 18/08/08

Docking Grange 21/02/08

Docking Grange 16/10/07

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 08/07/2008.

CARE HOME ADULTS 18-65 Docking Grange Sandy Lane Docking Kings Lynn Norfolk PE31 8NF Lead Inspector Mrs Lella Andrews Unannounced Inspection 3rd October 2006 10:45 Docking Grange DS0000066607.V315251.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.V315251.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.V315251.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 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) Caring Homes Healthcare Group Limited Position Vacant Care Home 34 Category(ies) of Learning disability (34) registration, with number of places Docking Grange DS0000066607.V315251.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. Date of last inspection Brief Description of the Service: Docking Grange is a private residential care home that provides accommodation for up to 34 Service Users. The home consists of the original building (Daphnes and the flat,) and three modern houses built at the rear of the home (Badgets, Caddows and The Coach House All bedrooms, except for one, are single and most of the bathrooms and shower facilities are suitable for use by Service Users with a Physical Disability. Whilst every Service User has their own house within the Home and staff are allocated to different areas, the Home is actually run as one. Many of the Service Users have lived at the Home for many years. The home has pleasant grounds, which are well maintained and accessible for all Service Users. 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.V315251.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains information gathered about the service since the last Inspection, which includes a random inspection in September 2006 and an unannounced visit to the service that took place over 6.5 hours on the 3rd October 2006. During the visit the Inspector was shown around the Home, spoke to residents, relatives and staff and inspected records. The acting manager was not present during the visit to the service and feedback was given to her the following day by telephone. The Commission received three completed comment cards from relatives and nine comment cards from residents. The residents were assisted by staff to complete the comment cards. In general, the responses in the comment cards were very positive with additional comments being made such as: “staff make you very welcome” “…nice and comfortable” “…everything’s good” The service was previously owned and managed by one family for many years and was bought by a new company in June 2006. A project manager employed by the company, Sara Goodwin, managed the service initially whilst a manager and deputy manager were recruited. Both of these posts were taken up in July 2006 and Ms Goodwin remained in post to offer support. The manager left in September 2006 and so Ms Goodwin remains as the acting manager whilst further recruitment is carried out. What the service does well: The residents still feel that they are receiving good care and that the staff are kind and helpful. The staff know the residents well and are enthusiastic about working at the Home. The majority of staff continue to feel well supported and feel that changes have been made for the benefit of the residents. The company have carried out a full review of the quality of the service and have plans for changes/improvements to be made. The Home has continued to be well managed. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 7 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.V315251.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. Appropriate information is gathered prior to a resident moving into the Home so that staff are aware of how to meet their needs. EVIDENCE: One resident has moved to the Home since the company took over in June 2006. The resident has a detailed care plan which provides information for the staff about how to meet his needs. The relatives of the resident said that they are very happy with the care that their relative is receiving and the support that the staff give to them also. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The process of updating care plans and risk assessments needs to be completed so that staff have good information about how to meet resident’s needs. The residents are encouraged to make their own choices about a range of issues. The arrangements for looking after resident’s money needs to be finalised. The management team have plans in place to improve all of the above issues and have started to implement them. EVIDENCE: During a random inspection in September 2006 a requirement was made for the care plans to be made more detailed so that they provide clearer information to the staff about how to meet the residents needs. This Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 10 requirement is repeated in this report. However, it was seen that the process of updating the care plans has started and that the new formats are much improved. The involvement of the residents in the care planning process is understood by the staff. All of the residents comment cards stated that they are aware that they have a care plan. The requirement for personal information not to be kept in communal records is repeated as the handover books still contain this information. The new format of the care plans contain more detailed risk assessments which will also provide better guidance for staff about how to manage identified risks. The staff work hard to support the residents to make their own choices and to have the information in order to make informed choices. The communication skills of the residents vary greatly and so staff need to have a range of skills to support residents effectively. The majority of the staff have recently attended an introduction to Total Communication and it is recommended that at least two staff now undertake the full training so that they are able to carry out communication assessments for each resident. The management team have good ideas about how to improve the opportunities for the residents to make their own decisions about a range of issues affecting their life. Resident meetings are due to start in each house shortly. The procedures for looking after the financial affairs of the residents are being changed to reflect that a new company owns the Home. Therefore, currently the situation is that the previous owners are still involved with these arrangements whilst the benefits agency amends appointeeship for some residents. The company has clear procedures for looking after resident’s money. These are being implemented and the management team will monitor this to ensure that it provides enough flexibility for the residents. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. Residents are supported to take part in a range of leisure/work activities. Support is given to residents to maintain relationships with friends and relatives. Residents enjoy their meals. Plans are in place to increase the resident’s involvement in the planning and preparation of meals. EVIDENCE: The residents take part in a range of leisure/work activities. This includes attendance at formal day services as well as more informal activities arranged by staff at the Home. The management team have recognised the need to review the current arrangements for residents who are at home during the day. As part of the review of the residents care plans their individual choices about activities will be included and this will then form the basis for plans to provide more individual activities. There is also recognition that many of the Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 12 residents are becoming older and frailer and that this may have an impact on how they wish to spend their time. The Home is situated in a village and residents are supported to use the local shop. Facilities within the wider community, such as the hairdressers, optician and dentists are being used more regularly for those residents who are able to, and wish to, access them. Residents told the inspector about the things that they like to do such as holidays, shopping, going out for meals, to the theatre. Each of the houses within the Home have television, video/DVD, music systems as well as books and craft materials for residents to use. The majority of the residents have their own televisions/music systems in their room. The residents completed comment cards all, except for one, stated that there are lots of things to do at the Home. The daily routines and staffing levels of each house are being reviewed by the management team to ensure that the individual needs/choices of the residents are being met. Staff who spoke to the Inspector have a good understanding of the needs of the residents and, in general, work hard to ensure that the routines are flexible. Staff were seen to knock on residents doors prior to entering. They are aware of the need to respect the privacy of the residents and gave examples of how this is done. Not all of the residents have a key to their room, as some would not be able to manage this. All of the completed comment cards from residents state that they are able to keep their own things private. Residents who are independently mobile are able to access all areas of the Home, apart from other people’s bedrooms. The residents who are less mobile are supported to go to other areas of the Home to mix with other residents and staff. The residents comment cards all, except two, state that they have a choice about what to eat. Only two of the nine stated that they are involved in the shopping for food. The arrangements for the planning and preparation of meals are currently under review with the intention that residents are more involved in the planning of menus, shopping and cooking. This will also increase residents choice about what they eat/drink. Staff join residents for meals in some instances. Staff were seen to support residents at mealtimes in a kind, respectful way. Residents said that they enjoy their meals and that the staff know what they like. The care plans contain information about the arrangements in place to support residents to maintain contact with their relatives/friends. Residents comment cards state that they are able to have visitors and the relatives comment cards Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 13 all state that they are made to feel welcome with an additional comment being made that staff “…make you feel very welcome.” Relatives who spoke to the Inspector said that they are able to visit whenever they like and that the staff go out of their way to be kind and supportive to them. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. Procedures are in place to ensure that the personal and healthcare needs of the residents are met. Medication is managed appropriately and a review has identified ways of improving the system in use. EVIDENCE: During the random inspection that took place in September evidence was seen that shows that health professionals are contacted and involved in the residents care as appropriate. Detailed records are kept about the health of the residents and of any interventions by health professionals. Staff have traditionally not been involved in supporting residents during GP/hospital appointments as the previous owners carried out these roles. Since the company took over in June staff now undertake this role and, as such, are feeling more involved in the care of the residents although some staff have found the new responsibility quite daunting. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 15 The care plans, as previously mentioned, are being updated and will include more detailed information about how to meet the residents needs with regard to mobility and personal care. The staff have a good understanding of how to meet the residents needs but during the random inspection it was found that assistance with mobility is not always provided in a consistent way so clearer care plans should help with this. Residents are clearly supported to make their own choices about clothes, hairstyles and makeup, as appropriate. There is only one male member of care staff and so it can be difficult for residents to have a choice about the gender of staff who support them. However, the male member of staff is sensitive to the needs of female residents and will usually only provide support with personal care to male residents. Residents have regular appointments with the dentist, optician and chiropodists as appropriate. All residents are registered with the local GP practice. The company has appointed a senior support worker, with another one to be appointed. This will mean that there will be a management team of four who will be responsible for monitoring the care provided and therefore identifying any areas of concern. A requirement was made during the random inspection for medication to be obtained as soon as possible as there had been a situation where this had not been the case. This requirement has been met with arrangements in place for prescriptions to be taken to another pharmacy when the GP dispensing pharmacist is not open. The medication system was seen in one of the houses and appropriate procedures are followed with records kept accordingly. It is recommended that the homely remedies policy is made clearer. The management team have reviewed the medication system and have identified some alterations, which will improve the system in use. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents are aware of who to complain to and procedures are in place to deal with these appropriately. The staff have received training and procedures are in place to protect the residents from abuse. EVIDENCE: The Home has a complaints procedure, which is on display in symbol format around the Home. The company has plans to produce this in audio format also. Nine of the residents comment cards state that the residents know who to talk to if they are unhappy and two stated that “sometimes” they know who to talk to. All the comment cards, except one stated that the residents feel safe at the Home. One answered “sometimes” to this question. Residents told the Inspector that they know who to tell if they have a problem and gave examples of how action has been taken to address issues that they had. The acting manager is aware of the complaints procedure and of the need to keep a record of complaints. The managers and staff all worked in a helpful and positive way with the Commission and Adult Protection team following a recent referral. During that Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 17 time the majority of staff spoke to the Inspector and all said that they are confident that any allegations of abuse will be dealt with appropriately by the management team. Almost all of the staff said that they are aware of the whistle blowing policy. A requirement was made during the random inspection in September 2006 for the staff to receive training with regard to the protection of vulnerable adults. This requirement has been met with almost all of the staff having attended training in the last fortnight. A further date has been booked for those staff that were not able to attend the original dates. The management team are in the process of reviewing all policies and procedures in the Home and the protection of vulnerable adults will be one of those to be updated shortly. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. In general, the Home provides accommodation which meets the needs of the residents but there are some areas of improvement needed which the company themselves have already identified. EVIDENCE: The Inspector was shown around all of the “houses” that make up the Home. All of the communal areas and a few of the bedrooms were seen. The acting manager said that the companies property department has carried out a full review of the maintenance, redecoration and refurbishment that needs to take place and that she is currently waiting for a copy of the timetable of works to be undertaken. In general, the Home provides homely, safe accommodation for the residents. Residents have been encouraged to personalise their own rooms, and to some extent, the communal areas. Two of the comments added to the residents comment cards about what is good about the Home are: “…nice and comfortable”, “…nice bedroom”. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 19 The majority of areas would benefit from redecoration and the replacement of some of the communal furniture e.g. Chairs, suites and tables. Some of the areas of more serious concern are highlighted below: In “The Flat” there is a step from the lounge to the kitchen. The shower also has a step into it. Two of the residents living here need a wheelchair for all their mobility needs and so currently staff have to lift the chair and the person up/down the steps. They also lift the hoist up/down the main step. The acting manager said that the maintenance staff are currently looking at suitable alternatives. It is required that this situation is addressed as a matter of urgency so that staff are not having to lift residents and equipment. Some of the baths and hand basins are badly stained and it is required that these are cleaned or replaced. The Inspector was told that the boilers in the three “houses” are not suitable for the number of residents living in each and therefore do not provide enough hot water. The acting manager said that this situation is being addressed. It is required that the boilers are suitable for the needs of the residents. Records show that a maintenance check by an external company has highlighted that one of the houses needs additional ventilation in the laundry room. The maintenance staff said that a report about this has been sent to the companies Head Office. It is required that this work is carried out. The telephone is based in the main office but due to the size of the site it can be heard in the houses. It was noted to be extremely loud in the dining room in “Daphnes”. It is recommended that a review of this situation is carried out and action taken so that the telephone does not cause such an intrusion to the lives of the residents. The three houses have their own laundry rooms whilst the other two living areas share the use of a main laundry room. There were no offensive smells noted during the visit to the Home. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The training and development needs of the staff have been reviewed with plans put in place for necessary training to take place over the next few months. Staff have started to receive formal supervision on a regular basis. Appropriate recruitment procedures are followed which provides protection for the residents. EVIDENCE: During the random inspection in September 06 a selection of recruitment files were seen and these show that appropriate recruitment procedures are being followed, including the necessary checks on new members of staff being undertaken. The Inspector was told that the company are currently reviewing the training and development that staff have already received and that plans are in place for future training sessions. A requirement was made during the recent random inspection for moving and handling training to be provided. This Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 21 requirement will be repeated in this report, as the training has not actually taken place yet although plans are in place. The company have already provided training in some subjects and have dates booked for additional training in the next few months. The Pre Inspection Questionnaire states that seven staff are currently undertaking NVQ level 2. The deputy manager said that more staff are due to start this shortly, therefore, the Home is moving towards meeting the target of 50 of staff having completed NVQ level 2. As previously stated, the company are undertaking a review of the residents needs with regard to staffing levels. The Inspector was told that currently they are recruiting for additional staff and that, where necessary, agency staff are used to cover shifts on occasions. The residents told the Inspector that staff are kind and that they are helpful. All of the completed comment cards, except two, from the residents state that they like living at the Home and that they feel well cared for. The two exceptions marked “sometimes” as the answer to those questions. Additional comments in the section asking about good things about the Home include: “...I get treated nice.” “I get helped”. Staff were seen and heard to support the residents in a kind, informal and relaxed manner. Staff interviews during the visit and during the random inspection showed that staff know the residents well and seem to genuinely care about them and their welfare. The residents appear to be comfortable around the staff. The requirement made during the random Inspection for records of supervision to be kept have been met. Discussions with staff and inspection of records show that supervision has started to take place on a regular basis but that not all staff have received this as yet. Staff said that they feel well supported by the acting manager and the deputy manager in the short time that they have worked at the Home. Records show that staff meetings have started to take place. The deputy manager said that the plan is to hold these separately for staff working in individual houses. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The Home is well managed in a positive and supportive way. The company are currently reviewing all aspects of the service provided with some action already taken to make changes/improvements. The health and safety needs of the residents and staff are given a high priority by the management team. EVIDENCE: The previous proprietors had owned and managed the Home for many years and this company took over in June 2006. One of the companies Project Managers, Sara Goodwin, worked as the acting manager from the first day. She continued to provide support to the manager and deputy once they were appointed in July 2006. The manager left in September 2006 and Ms Goodwin Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 23 has continued as the acting manager since then and intends to remain in post until another manager has been appointed. Recruitment for this post is ongoing. The deputy manager worked shifts as a member of the staff team when she first started at the Home to enable her to get to know the residents and staff but now works in a managerial capacity to enable some of the identified work to be carried out, such as reviewing the care plans. The deputy manager intends to undertake NVQ level 3 shortly. The company has reviewed the management support into the Home and has recently appointed a senior support worker with a plan to appoint another shortly. The senior support worker has a clear job description and there are plans in place for training and development within this role. Residents, staff and relatives clearly see Ms Goodwin as the manager of the Home. There will naturally be changes when new owners take over the management of a Home and particularly so when the previous owners managed the Home personally and the Home is now owned by an organisation. The majority of staff who spoke to the Inspector during the visit and the random Inspection feel that the pace of change has been appropriate and that the changes have been positive and in the best interests of residents and staff. However, some staff feel that the pace of change has been hurried and that not enough time has been taken to explain changes. The acting manager is aware of this and is discussing with staff as appropriate. The company is currently reviewing every aspect of the running of the Home and as such is reviewing the quality of the service provided. Action has already been implemented to make changes/improvements and plans are in place for further change to take place over the coming months. The acting manager is aware of the requirement for an annual quality assurance process to be carried out and a report to be completed with the results of the process. The health and safety needs of the residents and staff are being reviewed as part of the overall review of the service. Records show that regular maintenance/service of equipment is still taking place. During the visit it was noted that one such visit was over due and the deputy manager took action to rectify this immediately. The maintenance staff undertakes regular monitoring of health and safety issues such as visual room checks, fire alarm tests and water temperature tests. The Inspector was told that the hot water to baths, showers and hand basins is regulated and that window restrictors are fitted to all first floor windows. Some staff have attended Food Hygiene training with more dates booked for the rest of the staff team to attend. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 24 Requirements have already been made in this report relating to health and safety. The issues had already been highlighted by the management team but action had not yet taken place. Docking Grange DS0000066607.V315251.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 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 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X X 2 X Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? 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. The previous date of 31/10/06 was not met. It is required that personal information about the clients is not kept in a communal record. The previous date of 30/09/06 was not met. It is required that all staff receive training with regard to Moving and Handling. It is required that the situation regarding the step in “The Flat” is addressed satisfactorily so that staff are not lifting equipment and residents. It is required that the baths/hand basins that are stained are cleaned/replaced. It is required that the boilers in the houses are suitable to meet the needs of the residents. It is required that the ventilation is improved in the laundry room as per the maintenance advice. Timescale for action 31/12/06 2. YA6 12 (4) 30/10/06 3. 4. YA35 YA24 18 (1) 13 (4) 23 (2) 31/12/06 30/11/06 5. 6. 7. YA24 YA24 YA24 23 (2) 23 (2) 23 (2) 13 (4) 31/12/06 31/12/06 30/11/06 Docking Grange DS0000066607.V315251.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. Refer to Standard YA7 YA20 YA24 Good Practice Recommendations It is recommended that at least two staff attend the Total Communication Co-ordinators training. It is recommended that the Homely Remedies policy is made clearer. It is recommended that the telephone system is reviewed so that the sound does not cause such an intrusion to residents. Docking Grange DS0000066607.V315251.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Docking Grange DS0000066607.V315251.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!