Inspection on 25/08/06 for Eastbourne Grange

This inspection was carried out on 25th August 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 but made no statutory requirements on the home.

Other inspections for this house

Eastbourne Grange 24/07/07

Eastbourne Grange 06/12/05

Eastbourne Grange 16/06/05

Eastbourne Grange 04/02/05

Eastbourne Grange 21/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Eastbourne Grange 2 Grange Gardens Eastbourne East Sussex BN20 7DE Lead Inspector Jennie Williams Key Unannounced Inspection 25th August 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastbourne Grange Address 2 Grange Gardens Eastbourne East Sussex BN20 7DE 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) 01323 733466 eastbournegrange@btinternet.com Mr Trevor Pearce Mrs Patricia Pearce Mrs Patricia Pearce Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty-five (25). That service users must be aged sixty- five ( 65 ) years and over on admission. 6th December 2005 Date of last inspection Brief Description of the Service: Eastbourne Grange is a care home providing care for up to twenty-five (25) residents over the age of sixty-five (65). Nursing care is not provided at this establishment. There is a pleasant garden at the rear of the building. There is limited parking at the home, however there is free parking available in adjacent streets. Eastbourne Grange is a large semi-detached house in a quiet residential area of Eastbourne, close to the seafront, town centre and local amenities. There is access to public transport in the town. Rooms are located over three floors, with some mezzanine floors within the home. There is a passenger shaft lift available to assist residents to access all areas of the home. Fifteen rooms are for single occupancy and there are five double rooms. All rooms have en suite facilities. There are four communal toilets located throughout the home. There is one assisted bath and one assisted wheel in shower for residents to use. There are two lounges and a spacious dining area. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. Weekly fees range between £350 and £425. There are additional fees; hairdressing (£6 - £20), Chiropody (£8), newspapers and personal toiletries (varies dependent on residents choice). This information was provided to the CSCI on 16 June 2006. Residents/relatives know about the service through social service referrals, word of mouth and from living in the area. The home has a waiting list. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Eastbourne Grange will be referred to as ‘residents’. This unannounced inspection took place over eight hours on the 25 August 2006. Five residents were spoken with individually during the inspection and an additional 11 were spoken with during lunch. Ten resident surveys were sent to the home prior to inspection, of which five were returned. One care plan was looked at in detail. Specific areas of care needs were looked at in three other care plans. The Registered Manager and two staff were spoken with. Seven staff surveys were sent prior to the inspection of which five were returned. Three staff files were inspected. Out of five GP comment cards sent out prior to inspection, one was returned. One visiting relative was spoken with on the day of the inspection. A pre-inspection questionnaire was received prior to the inspection. A tour of the environment was provided and some individual rooms were viewed. Accident records and medication procedures were inspected. The quality assurance system was discussed with the Registered Manager and complaint records were viewed. Previous requirements at the home were assessed to ensure compliance. The staff rota and menus were viewed. The Inspector ate lunch with the residents. No health and safety records were viewed as this information has been provided in the pre inspection questionnaire. There were 16 residents residing at the home on the day of the inspection. The Registered Manager facilitated this inspection. What the service does well: The home has a good admissions procedure that ensures only residents whose needs can be met will be admitted into the home. Staff were observed to have a good professional rapport with residents. The home provides a good standard of care. The home has a good rapport with visiting health professionals, ensuring that residents’ health needs are being met. Visitors are welcomed at the home. Residents’ privacy and dignity are respected. All residents spoken with confirmed that their lifestyle within the home is their choice. Residents were complimentary about the food and are provided with a variety and choice of meals. Residents live in a comfortable environment and are able to personalise their individual rooms. Complaints Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 6 are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Residents spoken to were complimentary about the staff working at the home and benefit from continuity of care due to the low turnover of staff. Staff receive regular training to ensure they are skilled and competent to meet the needs of the residents. 75 of care staff have obtained a National Vocation Qualification level 2. The home is well managed and staff spoken with were complimentary about the Registered Manager at the home. What has improved since the last inspection? What they could do better: The Statement of Purpose requires to be reviewed to ensure there is clear information available for prospective residents/representatives on the facilities and services provided, to enable them to make an informed decision if their needs can be met at the home. Care plans need to provide clearer information on some specialist needs that individuals have. Some risk assessments are in place but additional ones need to be implemented, with particular attention to falls to ensure any activity that poses a risk is identified and eliminated so far as is practicably reasonable. A policy for dealing with medication when a resident goes on social leave needs to be developed to ensure any medications provided to the home can be accounted for. Creams must be removed from communal areas and it has been recommended that any handwritten prescriptions on MAR charts should be checked and double signed by two staff who have undertaken medication training and any hand written amendments on MAR charts are to be signed. Residents will be better safeguarded if there is a clear procedure in place for dealing with allegations of abuse. Other requirements made to ensure residents are safeguarded are: that a robust recruitment procedure is implemented, that hot water is delivered around the recommended 43°C and that all windows are restricted. A more structured quality assurance and quality monitoring system would enable management to monitor the success of the home in meeting its aims and objectives. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 7 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. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The Statement of Purpose requires to be reviewed to ensure there is clear information available for prospective residents/representatives on the facilities and services provided, to enable them to make an informed decision if their needs can be met at the home. The pre-admission assessment undertaken ensures that only residents whose needs can be met are admitted. EVIDENCE: A copy of the Statement of Purpose and Service User Guide was sent to the Inspector following the inspection. This document provides the prospective residents with a detailed list of the aims and objectives of the home but does not clearly provide all the information as required in the regulations, such as; relevant experience of the Registered Provider and Registered Manager, the number and size of rooms in the care home, the number and relevant qualifications and experience of staff etc. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 10 Of the residents that were asked, all confirmed that they or a representative were provided with sufficient information about the home and the services provided prior to moving in. All prospective residents are assessed prior to moving into the home and are provided with an opportunity to visit the home prior to moving in. Of the residents that were asked, all confirmed that someone from the home came to assess them prior to moving in. Residents confirmed that they or a representative visited the home prior to moving in. It is stated in the terms and conditions that the first four weeks are considered as a trial period to ensure the resident is happy at the home and that all needs can be met. Pre admission assessments viewed demonstrated that the home does not admit anyone whose needs cannot be met at the home. Copies of social services care plans or other health professional’s information is obtained wherever applicable. The Registered Manager confirmed that there was no one residing at the home from any minority ethnic communities, social/cultural or religious groups with any specific need or preferences. The home does not have dedicated accommodation to provide intermediate care. Respite care is available if there is a vacancy. The home does not take emergency admissions. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Staff will be provided with clearer information on the assessed needs of individuals when the new care plans are implemented for all residents. Residents’ privacy and dignity are respected. EVIDENCE: A new care plan format is just being implemented. As care plans are being reviewed, the information pertaining to individuals is being transferred onto the new format. Some residents spoken with confirmed that they are familiar with their care plans and all their needs are being met at the home. The Inspector noted that some information pertaining to individuals had not been incorporated into their care plan, such as a resident undertaking their own blood sugar levels, specialist dietary requirements. Other care plans inspected provided the carers with clear information about the care needs of the individual. The Registered Manager is aware of the limited information in the some of the care plans and is addressing this as the new format is being implemented for each individual. This has not been reflected as a requirement as there is evidence Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 12 that work is being done to address this shortfalls. This will be assessed again at the next inspection when the new care plan format will be implemented for all residents. Each resident has a personalised daily itinerary in place that provides quick easy information on the daily preference of the individual eg; their preferred waking up time, what drink they prefer in the morning, what assistance they require etc. Additional work is required to ensure all residents have a thorough risk assessment in place, with particular attention to falls. Risk assessments must be implemented for those residents who independently go out into the community. Four of the residents surveys received confirmed that they always receive the care and support they need. One comment received was ‘staff are very attentive’. A visiting relative spoken with confirmed that the staff discuss their relatives care with them. Residents care plans are reviewed on a monthly basis or earlier if the needs of an individual changes. The Registered Manager confirmed that the home has pressure-relieving equipment available when required. Nursing care is not provided at the home, however district nurses will provide nursing input if required. Medical or specialist advice is sought when required. All resident surveys received demonstrated that residents receive medical attention when required. The GP comment card received demonstrates that they are satisfied with the overall care provided to residents within the home and that staff demonstrate a clear understanding of the care needs of residents. Some residents were observed to be wearing glasses and of those asked, all confirmed that they receive an annual eye test or whenever they request. Some residents spoken with confirmed that a chiropodist visits the home and dental appointments are arranged when needed. It was confirmed that there are policies and procedures in place for all aspects of dealing with medications. The content of these were not read. The home now uses blister packs that are supplied monthly from their pharmacist. There was no procedure in place for dealing with medications when a resident may go on social leave for a period of time. There are records kept of all incoming and outgoing medications. Some prescriptions on Medication Administration Records (MAR) charts had hand written amendments on them, that had not been signed to show who had made the changes. Any handwritten prescriptions on MAR charts should be checked and double signed by two staff who have undertaken medication training, to ensure staff and residents are safeguarded from errors being made. Sample signatures are kept of all staff administering medication. The Registered Manager confirmed that all staff who administer medication have been trained to do so. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 13 MAR charts inspected demonstrated that medication is being signed for at the time of administration. There are clear records of controlled drugs being kept. Residents are provided with an opportunity to self medicate, based on a risk assessment being undertaken. The content of these were discussed with the Registered Manager. The risk assessments should identify clearly that the resident is fully aware of the importance of the safekeeping of medication and are mentally fit to do so. There were some creams prescribed for individuals found in communal bathrooms. Unlabelled creams were also observed to be kept in communal areas. Of the residents that were asked, all confirmed that they felt their privacy and dignity are respected. Staff were observed to knock on individual room doors prior to entering and were heard to call the residents by their preferred term of address. Some rooms were noted to have their own personal telephone installed. Residents may arrange to have a phone in their room at their own cost. The GP comment card shows that they are able to see their patients in private. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: Four resident surveys received demonstrated that there are activities arranged by the home that they can take part in. All residents spoken to confirmed that there are enough activities for them to participate in if they choose to be involved. Residents spoke positively about the provision of activities at the home. All residents spoken with confirmed that their lifestyle within the home is their own choice and are able to make their own decisions regarding their daily routines. Residents were observed to move freely around the home. Residents in their rooms confirmed that they remained there by choice. A relative and staff spoken to felt that there were sufficient activities provided for the residents. Some of the activities provided include: bingo, quizzes and arts and crafts. Residents who are capable to go out into the community on their own are encouraged and supported to do so. A visiting relative spoken with confirmed Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 15 that there are no restrictions for visiting and is welcomed at the home and find the staff very friendly. There is a visitor’s book that all people must sign upon entering and leaving the home. Residents were complimentary about the food provided at the home and confirmed that they have a good variety of choice. A resident commented that there is always tea and coffee available at any time. The menus provided to the Inspector demonstrated that there are a variety of nutritional meals available. One resident commented that they wanted Chinese food at one time and this was provided for them. Two residents spoken with who had specialist dietary needs stated that the home was ‘accommodating for dietary needs’ and ‘the chef is knowledgeable on diabetes’. The dining room is only accessible by a passenger shaft lift from the ground floor. The Inspector ate fish and chips with the residents and lunchtime was observed to be a relaxed social time for residents. Staff were present to offer discreet assistance to residents if needed. Residents were observed to be enjoying their meal. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Clearer written policies and procedures for the Protection of Vulnerable Adults (POVA) will better safeguard staff and residents. EVIDENCE: The home has a complaints procedure in place. It was discussed with the Registered Manager that the contact details of the CSCI be included in this procedure. An updated copy of the homes complaint procedure was forwarded to the CSCI following the inspection. Residents surveys received demonstrated that residents know who to speak to if they are not happy about something and know how to make a complaint. Of the residents that were asked, all confirmed that they knew who to speak to if they had any concerns. The home has received two complaints since the last inspection. One was regarding the meal times sometimes as being late. This was partially substantiated. The other concern raised was regarding the cleaning within the home and uncertainty of who was responsible for which areas. Records are kept of all complaints and demonstrate that the home investigates these in an unbiased manner. A copy of the Protection of Vulnerable Adults (POVA) procedure was forwarded to the Inspector following the inspection. This procedure needs amending to clearly state that all allegations of abuse must be referred to social services, Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 17 who are the lead authority. No investigation should be undertaken by the home without guidance from social services. There has been one POVA investigation since the last inspection. The home followed the correct procedures following initial contact with the Inspector, who advised the home to contact social services. The outcome was unsubstantiated due to insufficient evidence being available. The home took appropriate action to resolve this incident. A staff member spoken with confirmed that they have received POVA training. All staff surveys received also demonstrated that they are aware of adult protection procedures. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: The home is generally well maintained. Any minor faults noted by the Inspector on the day of the inspection were mentioned to the Registered Manager. Of the residents that were asked, all confirmed that they were happy with their rooms and were able to personalise them. Individual rooms viewed showed that some rooms had been personalised to reflect the choice and personality of the individual. Residents are able to access a pleasant garden area and the rear of the house also overlooks a secluded park. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 19 Hot water taps are regulated, however on sampling some of these the Inspector noted that hot water was being delivered between 41°C and 50°C. The home needs to ensure that taps are clearly marked hot and cold to prevent any confusion for the residents. On tour of the home there were some windows noted to be unrestricted. Some extractor fans were also observed to be in need of cleaning. Advice and quotes have been obtained for repairs to the boiler room ceiling, which is need of repair. There was an area under the stairs on the ground floor that had comfortable sitting chairs near a bookcase. Residents are not able to access these books due to this area being used as storage for wheelchairs. It was noted that there were hand towels in communal areas. This practice does not promote good infection control and suitable measures should be implemented. This included the communal toilet near the entrance of the home that the cook also uses. It was confirmed that the cook also has a sink within the kitchen that is used to rewash their hands. The residents’ surveys received stated that they always find the home fresh and clean. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents’ needs are being met with the number and skill mix of staff on duty at all times. The recruitment procedure needs to be more robust to safeguard residents. EVIDENCE: Residents spoken to were complimentary about the staff working at the home and confirmed that there were enough staff on duty. They confirmed the only time that the home may be short staffed is due to holidays or sickness. A visiting relative also commented that in their opinion there were sufficient numbers of staff on duty. The rota provided to the Inspector demonstrates that there are usually four or five staff working in the morning and three working in the afternoons. There is one waking night care staff on duty. Three resident surveys received demonstrate that staff are always available when needed and two stated that usually staff are available. Some comments written and spoken to the Inspector were; ‘staff are very friendly and kind’, and ‘wonderful and cheerful and I couldn’t be treated better, it is like living at the Grand Hotel’. There is currently eight care staff employed at the home. Turnover of staff at the home is very low and residents benefit from continuity of care. Six of the care staff have obtained National Vocational Qualification level 2. This equates to 75 of care staff having achieved the relevant qualifications. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 21 The recruitment procedure needs to be more robust. On inspection of staff files, it was noted that staff had commenced employment prior to a POVA First or CRB check having been obtained. A full employment history had not been provided for some staff and there was no evidence that gaps in employment had been explored. No references were found for one staff member. All staff surveys demonstrate that they received induction training and are provided funding and time for them to receive other relevant training. The pre-inspection questionnaire demonstrates that some recent training provided to staff include: adult abuse, infection control, food hygiene and medication training. Some staff are also undertaking long distance training, including health and safety and equality and diversity. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The home is generally run in the best interest of residents, however a more structured quality monitoring system would enable management to monitor the success of the home in meeting its aims and objectives. EVIDENCE: The Registered Manager is also one of the registered providers. She is a registered nurse that has maintained her registration with the Nursing and Midwifery Council. The Registered Manager has had approximately 20 years of experience in a variety of management positions. The Registered Manager commenced the Registered Manager Award course in May 2006. Staff and residents were complimentary about the Registered Manager. Some comments received and written on surveys were: ‘there is easy access to the Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 23 management team, they are always very open to new ideas’, and ‘a very caring and fair employer’. There is a quality monitoring system in place, however it was discussed with the Registered Manager that this becomes more structured. The Registered Manager informed the Inspector that questionnaires for residents are done every few months and they try to get relatives to complete questionnaires every 6 months. The Registered Manager confirmed that no quality monitoring had been undertaken since the last inspection. It was confirmed that there are resident meetings held every six months. It was discussed with the Registered Manager that feedback also be sought form GP’s, district nurses and other visiting health professionals. The Registered Manager confirmed that she runs the home with an open door policy and staff meetings are held every six months. Questionnaires for staff should also be developed as part of the quality monitoring system. The home is not an appointee for any resident and does not hold any personal allowance. The Registered Manager confirmed that all staff are kept up to date with mandatory training. The pre-inspection questionnaire demonstrates that fire alarms are tested weekly and that the most recent fire drill was in March 2006. The Registered Manager confirmed that hot water checks are done every month. The Registered Manager undertakes at least monthly checks on the environment, however as she is at the home on a daily basis, these are not recorded. It was recommended that as part of the homes quality assurance that a quick checklist is devised for the Registered Manager to complete when undertaking the monthly environment checks. No health and safety records were inspected on this occasion as this information has been provided in the pre-inspection questionnaire. Any shortfalls noted in health and safety during the inspection has been highlighted in the relevant sections of the report. Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 25 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. 2. Standard OP1 OP7 Regulation 4&5 Schedule 1 13(4) (b&c) 13(2) 13(6) Requirement That the Statement of Purpose and Service User Guide contain all the required information. That risk assessments are implemented for all service users, with particular attention to falls. That all creams are removed from communal areas and used only for those it is prescribed. That the POVA procedure provides clear guidance for staff that it is not for the home to undertake any investigations. All allegations must be referred to social services. That hand-drying towels are removed from communal bathrooms and alternative measures implemented. That all staff must have at least a POVA First check undertaken prior to employment and work supervised until a full enhanced CRB is returned. That all staff files comply with Schedule 2. That a more structured quality assurance and quality monitoring DS0000021091.V298484.R01.S.doc Timescale for action 30/11/06 30/11/06 3. 4. OP9 OP18 03/11/06 30/11/06 5. OP26 13(3) (4)(c) 19 30/11/06 6. OP29 03/11/06 7. 8. OP29 OP33 Schedule 2 24 03/11/06 30/11/06 Eastbourne Grange Version 5.2 Page 26 9 10. OP38 OP38 13(4) (a&c) 13(4) (a&c) system be implemented. That hot water is delivered around the recommended 43°C. It is required that restrictors be fitted to all upper floor windows. (Timescale 31.12.05 not met) 15/11/06 15/11/06 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. Refer to Standard OP9 OP9 Good Practice Recommendations That the risk assessments for the service users who selfmedicate be expanded. That a policy and procedure be developed for when medication is taken home with the individual to ensure all medication provided and administered can be accounted for. That handwritten prescriptions on MAR charts be checked and double signed by two staff who have undertaken medication training. That any hand written amendments on MAR charts are signed. 3. 4. OP9 OP9 Eastbourne Grange DS0000021091.V298484.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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