Inspection on 30/12/09 for Docking Grange

This inspection was carried out on 30th December 2009.

CQC 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 CQC 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Docking Grange 03/02/09

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 16/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Docking Grange Sandy Lane Docking Kings Lynn Norfolk PE31 8NF Lead Inspector Lella Hudson Key Unannounced Inspection 30th December 2009 09:40 Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 1 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 home adults 18-65 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. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 2 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 Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 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.caringhomes.org 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) Manager Post Vacant Care Home 34 Category(ies) of Learning disability (34) registration, with number of places Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 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 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.V378845.R01.S.doc Version 5.3 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 (February 2009). It includes information provided within the Annual Quality Assurance Assessment which was completed by the Manager and within the completed resident and staff surveys which were returned to us. As part of the Inspection process we carried out an unannounced visit to the Home on the 30th December 2009 between 9.40am and 4.50pm. During our visit we spoke to senior managers of the organisation, staff at the Home and to residents. We looked around the communal areas of the Home and also inspected a selection of records. The Manager of the Home, Matthew Dale, was appointed in August 2008 and is not yet registered with the Commission. The Manager was not at the Home during our visit. What the service does well: What has improved since the last inspection? Some of the residents have been on holiday and there have been additional activities arranged in preparation for Christmas. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 6 Some areas of the Home have been decorated and new furniture and equipment purchased. The care plans contain more detailed guidance for staff about how to meet residents needs, although further improvements are still needed. Recruitment has taken place so that there is less reliance on the use of agency staff. What they could do better: 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. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 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.V378845.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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 appropriate procedures in place for the admission of residents EVIDENCE: There have not been any admissions to the Home since the last Inspection. According to the AQAA the Home has an effective admissions procedure. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. The care plans contain guidance for staff about meeting residents basic needs but some would benefit from more detail. The views of the residents are being sought and planned work on communication skills will make this easier. EVIDENCE: We looked at two of the care plans and can see that the improvements that we saw at the last Key Inspection have continued. The care plans are written in a more person centred way and contain detailed information about how to meet residents needs. There are good reminders to staff about respecting privacy and dignity. However, there are still areas which need further detail so as to be able to provide staff with clear guidance about how to meet the residents needs. The example we saw was for a resident who may have aggressive behaviour Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 10 towards other residents and staff. There is currently no clear guidance for staff about how to manage these situations. There is evidence that regular reviews are taking place of the care plans. The care records contain risk assessments but again, there are areas, such as aggression for which there are not adequate risk assessments. The care records still do not contain detailed financial plans. 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 it is not clear how much each resident is entitled to, or what the arrangements are for obtaining their money. The AQAA states that there are plans to set up individual bank accounts for residents. There are several residents at the Home who have difficulties with verbal communication. At the time of the last Key Inspection some of the staff had attended training with regard to Communication and there were plans to put some of this training in place. However, this has not taken place. Recently this work has started again and five of the staff have attended the Communication training. We spoke to one of the staff who is taking a lead with regard to the introduction of alternative forms of communication. She is very enthusiastic and is keen to introduce new ways of working across the Home. We could see that some of the ideas have already been implemented, such as the use of pictures in one of the residents bedroom to enable them to find their clothes more easily. One of the comments in the social/healthcare professionals surveys is that a positive aspect of the Home is that they have “begun to address the residents communication needs”. This work is a positive step towards enabling residents to have more say about how they live their lives and to make their own choices. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 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. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 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. Residents receive a varied diet and have choices about what they eat. Residents are not supported to take part in meaningful activities on a regular basis. EVIDENCE: We spoke to residents and staff about the range of activities that the residents are involved with. We also received many comments about activities within the surveys that we received. At the time of the last Key Inspection some improvements had been made to ensure that the residents were able to take part in meaningful activities. The situation that we found during this visit is that that although there have been improvements since the last Inspection and that staff are working hard to enable residents to experience a range of activities that there are still long Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 12 periods of time when residents are not engaged in anything. For some residents, there are also long periods of time when they do not leave the Home. At the time of the last Key Inspection we were told that there were plans to recruit a part time activities co-ordinator. This has not happened but the AQAA states that there are still plans to recruit to this post. In November/December 2009 we received two anonymous complaints about the Home. These both stated, as part of the complaint, that the staffing levels are not adequate to ensure that residents are able to take part in activities. 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 and residents are reliant on appropriately trained drivers to be available. Some of the residents attend formal day services during the week but at weekends all of the residents are at home. There are no additional staff on duty at weekends or during holiday periods when the day centres are closed. Staff and residents told us about the range of holidays that the residents were supported to take part in over the last year as well as the Christmas shopping and other Christmas activities that took place just prior to our visit. Staff have started to update the activity room and try to use this on a more regular basis. Some of the staff whom we spoke to are very enthusiastic about supporting the residents with activities and have lots of ideas. The responses within the staff surveys with regard to activities were mostly stating that residents are not being supported to take part in enough activities although there were a couple of comments about the improvements in this area over the last year. The staffing situation has been variable over the last year and at times when the staffing levels drop then it is particularly difficult for staff to support residents to take part in activities that are meaningful for them as individuals. The meals that we saw during our visit looked appealing and appetising. Residents who needed support were being provided with this in a sensitive manner. Each area of the Home is responsible for their own menu planning, food shopping and cooking. Residents are encouraged to take part in these tasks. A cook is employed for four days a week to do the cooking in Daphnes and Hollies. There are plans to employ another cook so that this is provided seven days a week. In the other areas of the home the care staff are responsible for the cooking. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 13 Staff told us that there have been difficulties in obtaining money from Head Office to do the food shopping. We passed this situation on to the Area Manager and he agreed to investigate as he was unaware of this and felt that the procedures in place should ensure that there is always enough money for this to take place when needed. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. The personal and healthcare needs of the residents are met but difficulties in staffing have meant that there are times when it is more difficult for staff to do so. Medication is managed safely. EVIDENCE: We spoke to staff about the support that residents need and spent some time observing staff with the residents. Staff spoke to the residents kindly and respectfully. The needs of several of the residents have increased since the time of our last visit. Many of the residents have physical disabilities or disabilities associated with ageing. This means that they require a high staff input to enable their personal care needs to be met. Discussions with staff and an inspection of staff rotas confirm the views within the staff surveys that there have been times when the staffing levels have not been adequate to meet the residents needs in a consistent way. We can see Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 15 that there have been periods of consistency, and other times when the staffing levels have been such that staffing levels have meant that it has been difficult for staff to do more than provide basic care to the residents. We received 9 staff surveys and 5 stated that there ‘sometimes’ enough staff to meet the residents needs, 2 stated ‘usually’ and 2 stated ‘never’. Several staff had written additional comments on the surveys with regard to the staffing levels and meeting the residents needs. For example: ‘we are only providing basic care’ ‘need more staff’ Need to improve staffing levels’ The care records include evidence of residents having contact with health and social care professionals. There are records of reviews and of health appointments. One of the care plans that we saw had been updated with detailed guidance about how to meet a residents needs following a period of ill health. We received one survey from a health/social care professional. This states that the staff usually seek advice appropriately and act on it. It states that the staff always respect the residents privacy and dignity. Some additional comments made are: ‘there are some enthusiastic staff’ ‘the reviews are very positive’ ‘there is a need to ensure that the review outcomes are completed’ At the last Inspection we were told that the Health Action Plans, as recommended by health professionals, were going to be implemented. The AQAA states that these are in use but need further work. We did not see any evidence of these being used for the residents. We looked at the medication system in use at one of the houses and spoke to the senior carer about the system in use at the smaller houses. The medication was stored appropriately and records completed for medication received at the Home and that which is returned to the pharmacy. We did not see any errors in administration records but the Homes own audits have identified some errors recently. New monitoring systems have been implemented and the member of staff said that this has effectively addressed the situation. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Complaints are taken seriously and action taken to address issues. Staff receive training and there are procedures in place to protect the residents from abuse. EVIDENCE: The planned communication work will increase opportunities for residents to be able to ‘have a voice’, which will include being able to raise any concerns that they have. The Home has a complaints procedure, which uses pictures as well as words, on display around the Home. We received two complaints in the month prior to our visit to the Home. Both were anonymous and both related to staffing levels and the effect this was having on residents. One complaint also related to concerns about the management of the Home and the length of time taken to address problems with equipment when faults occur. We passed one of the complaints on to the Area Manager to investigate which he did and provided us with a full report about the issues. The training matrix shows that there are 12 staff, out of a team of 35, who have not had Safeguarding training in the last eighteen months. This training is being provided at the Home at the end of January. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 17 The health/social care professionals survey stated that any concerns are always dealt with appropriately and the staff surveys all stated that the staff know what to do if any concerns are raised with them. During our visit we became aware of a situation that had occurred a couple of days previously. This had not been referred to Safeguarding as it should have been although the Area Manager dealt with it as soon as we made him aware of the situation during our visit. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. The quality of the accommodation is mixed due to the fact that it is provided in a range of different living environments. EVIDENCE: The organisation has made many improvements to the accommodation over the last few years and there are plans for further improvements. Accommodation is provided in five different locations. The main house provides accommodation for residents with additional physical disabilities. Part of the first floor of the main house provides accommodation for a smaller group of residents. There is a passenger lift in the main house. There are also three smaller, separate houses which are located in the grounds of the main house. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 19 Some areas of the Home are attractively decorated and furnished in a homely way whereas others are more basic and not so homely. Residents are encouraged to personalise their bedrooms in their own style. In the three smaller houses the staff are responsible for the cleaning and try to encourage residents to be involved in this. There is a member of staff employed to carry out domestic tasks in the main house. There were no unpleasant smells in the Home on the day of our visit. We noted that one of the bedrooms was in need of vacuuming and the bin was full. The resident had been away for several days. One of the complaints that we received stated that it often takes a long time for equipment to be mended or to be replaced. The Area Manager confirmed that there had been some problems with the boilers in the smaller houses but that suitable alternative arrangements had been put in place. One of the concerns was with regard to one of the beds, this is being addressed. The specialist bath, which is in the main house, has been out of use for several months as there have been problems with the manufacturers obtaining the parts. This means that there are some residents who are unable to have a bath. There is a shower available. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. The staffing situation has not been consistent over the last year despite attempts to maintain a permanent staff team in adequate numbers. The provision of training has also varied. EVIDENCE: As previously mentioned in this report there have been difficulties with the staffing situation at the Home. The organisation has worked hard to recruit new staff so that there is a permanent, consistent staff team. There have been difficulties recruiting in such a rural area. Agency staff have been used when the staffing situation has been difficult but there have still been times when staffing levels have meant that it has been difficult to provide a good standard of care to the residents. The views within the staff surveys were mixed with regard to the morale at the Home and whether the staff receive good support to enable them to carry out their roles effectively. When we spoke to staff during our visit we also received mixed views about this. There have clearly been some times when Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 21 the staffing situation has been difficult and there have been difficulties within the management team which have meant that staff have not always felt happy at working at the Home. Some of the comments we received are as follows: ‘there has been no training lately’ ‘we need more staff’ ‘we need better communication in the staff team’ ‘lack of supervision’ ‘it’s a relaxed, friendly atmosphere’ ‘its an enjoyable place to work’ ‘there have been lots of improvements in the last 6-8 months’ There has been a change in the hours of the shifts during the day. There is now a shorter handover period so that staff are on shift until later in the evening so as to support residents at that time. The training matrix shows that there are some staff who have received all mandatory training within the last few months and some who do not appear to have received this at all. Some of these staff may have only recently started work at the Home. There are notices up about forthcoming training with regard to Safeguarding, Fire Safety, working with people with challenging behaviour and the LDQ training. Staff who spoke to us were enthusiastic about wanting to attend training. The matrix we were given does not include information about any training other than mandatory. Staff told us that there is little other training, for example, about specific issues affecting residents. The organisation has its own training department who provide some training sessions. Some training is provided by external trainers and other training is provided through the use of computer e-learning. The senior care staff have received training with regard to the provision of supervision to care staff. The views of staff are mixed with regard to whether they receive good supervision and support to carry out their roles effectively. We looked at two staff recruitment files. One of these contained references which were dated after the date that the member of staff started work at the Home. The information about the Criminal Records Bureau check is not detailed enough as it does not state what level it was obtained at nor does it contain any information about the outcome ie. that a decision was made to employ the person. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Management of the Home has been inconsistent recently, with a lack of leadership. Health and safety is taken seriously. The organisation has an effective quality assurance system. EVIDENCE: The Manager started working at the Home in August 2008. He has relevant experience and qualifications to manage the Home. The Manager has not started the process of becoming registered with the Commission. The Manager has made a lot of improvements to the Home since he was employed and at the time of the last Inspection he had lots of plans for further Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 23 improvements. This report has included examples of further improvements that have been made in the last year, however, there have also been some difficulties with regard to the management of the Home in the last few months. The Manager has been away from the Home a lot and the deputy manager left the Home in December 2009. The Home has senior care staff and a lot of responsibility has been left to them. The Area Manager has increased his visits to the Home and is available at other times by telephone. The staff told us that the Area Manager has been very supportive and helpful. They said that he addresses issues as they arise. The organisation has a well developed quality assurance system, and therefore have already identified the issues that have been raised in this report. In addition to this they have already taken action to start to address the issues. We saw that regular servicing and maintenance of equipment takes place. Fire training is provided to the staff team. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 24 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 2 23 2 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 2 35 2 36 2 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 1 13 3 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 2 3 X X 3 X Version 5.3 Page 25 Docking Grange DS0000066607.V378845.R01.S.doc 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 YA35 Regulation 18 Requirement It is required that staff receive appropriate training to enable them to carry out their roles. This requirement was made at a previous Inspection with a timescale of 31/05/09 It is required that residents are supported to take part in meaningful activities It is required that the staffing provision is adequate to consistently meet the needs of the residents Timescale for action 30/04/10 2. 3. YA12 YA33 16 18 28/02/10 21/01/10 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. Refer to Standard YA7 Good Practice Recommendations It is recommended that the amount of benefit that each resident is entitled to is recorded Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 26 Care Quality Commission Eastern 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). 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. Docking Grange DS0000066607.V378845.R01.S.doc Version 5.3 Page 27 - 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!