Inspection on 11/02/06 for Grafton Lodge

This inspection was carried out on 11th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grafton Lodge 18/07/07

Grafton Lodge 06/01/07

Grafton Lodge 09/09/05

Grafton Lodge 03/02/05

Grafton Lodge 09/08/04

Grafton Lodge 25/02/04

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

CARE HOMES FOR OLDER PEOPLE Grafton Lodge Grafton Road Oldbury West Midlands B68 8BJ Lead Inspector Lesley Webb Unannounced Inspection 11th February 2006 09:00 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 Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 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. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grafton Lodge Address Grafton Road Oldbury West Midlands B68 8BJ 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) 0121 559 3889 0121 559 0708 Sandwell Metropolitan Borough Council Care Home 36 Category(ies) of Dementia - over 65 years of age (36) registration, with number of places Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the pre-registration report of 13 January 2003 are met within the timescales contained within the action plan agreed between Sandwell Metropolitan Borough Council and the National Care Standards. Day care provision must not encroach on the facilities, staffing and services provided to residential service users One service user accommodated at the home may be DE. This will remain until such time that the service users placement is terminated. 9 September 2005. 2. 3. Date of last inspection Brief Description of the Service: Grafton Lodge is owned by Sandwell Metropolitan Borough Council and is committed to providing an individual approach to care for older people with mental health needs, the majority being with moderate to severe forms of dementia. Grafton Lodge is situated 2 miles from Oldbury and within easy access of Blackheath, Dudley and Birmingham. The home is situated approximately 2 miles from the M5, junction 2. Rowley railway station is within walking distance and a number of bus routes (449, 88, 123) frequently pass the unit in Grafton Road. Local amenities are within walking distance of Grafton Lodge, these include a church, shops, post office, take away food outlets, golf course, public house, restaurants and a doctors surgery. Grafton Lodge has 36 single bedrooms, (including one en-suite room), these being in two 18 bedded units, one on each floor, with 5 beds being specific to respite care on the upstairs unit. The home offers a passenger lift, and has various aids and adaptations. To the rear of the property is a patio and garden, which provides residents with a pleasant outdoor area. Car parking space is available at the side of the home. The home has its own transport. A range of services are available at Grafton Lodge, which are detailed in the homes Service User Guide. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived at 9am and stayed until 6.45pm. Due to all the residents at the home have various levels of dementia the inspector was unable to have constructive discussions with them to find out their views and opinions on service provision. Time was however spent formally interviewing staff, indirectly observing care practices and looking at records before giving feedback to the acting manager. Since November 2005 an acting manager has been in post at the home who previously was registered to manager another home owned by Sandwell Metropolitan Borough Council. An abundance of compliments were received regarding the acting manager and the support and guidance she has given to staff at the home, with the only concern raised by staff being the future management of the home. The inspector discussed this situation with the acting manager including the fact that there has been no permanent manager in post for over a year, stressing the urgency for this situation to be resolved before it affects the moral of staff and ultimately care provided to residents living at the home. As this is the second inspection to take place in twelve months both this report and the one published September 2005 should be read when looking at how the home is achieving national minimum standards. By the end of the visit the inspector was satisfied that many improvements have been made at the home, further enhancing the quality of service provided at the home. The inspector would like to thank everyone for his or her cooperation and assistance shown during the day where she was made to feel very welcome. What the service does well: All staff that were either spoken to or formally interviewed demonstrated knowledge and understanding of their roles as advocates for residents. For example one member of staff explained, “a lot of people here cannot speak for themselves so we have to act in their best interest” and another, “dementia can make it hard for people to tell us if they are not happy so we have to look out for things that might not be their normal behaviour, we take this to mean they might be unhappy. We have a responsibility to act on this, to report and record”. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 6 There is a very friendly and relaxed atmosphere at the home. Throughout the visit the inspector witnessed staff laughing and joking with residents, encouraging them to join in activities and talking in a relaxed yet respectful manner. The home as a very good quality assurance system with an abundance of evidence that monitoring takes place to ensure standards are maintained. The inspector was also pleased to find that many staff understood the important of quality monitoring, for example one person stated, “monitoring makes sure we provide a complete service, giving service users a total quality of life. It makes sure we deliver a good service not just once but everyday at the best level possible”. Other areas where the home provides a good service include its admission assessments, resident’s contracts/terms and conditions of residency, health care monitoring and the management of resident’s finances. What has improved since the last inspection? The area that the inspector found most improvement was that of record keeping. Since the acting manager has been in post she has restructured many systems required for the effective management and monitoring within the home. This has resulted in organised systems that support staff to carry out their roles. The home has also made good progress to address many requirements identified in previous inspections. Since the last inspection residents and/or their representatives consent to personal care given by someone of the opposite sex has been gained, advice from a dietician has been sought regarding menus and meal taken at lunchtime are now being recorded. Also the majority of staff working at the home have undertaken adult protection training and the whist blowing policy has been discussed in staff meetings and supervision, staff deployment around the building has improved and programmes have been instigated to ensure staff receive regular support in the form of one to one supervisions and staff meetings. Improvements have also been made to the environment with the decoration of many communal areas of the building, the continued installation of double electric sockets in resident’s bedrooms and the implementation of requirements made by both the fire and environmental health department. The home has also sought advise from the infection control advisor in relation to the cleaning and sanitising of commodes with investigations currently in progress to improve systems currently in place at the home. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 7 The inspector looks forward to seeing continued improvements in the above areas when next visiting the home that will then evidence requirements met in full. 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. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 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 Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 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, 2, 3, 4, 5 and 6. The homes statement of purpose and service user guide contain basic information. Further development will ensure prospective residents can make a more informed choice on suitability of the home. The homes terms and conditions of residency ensure residents are aware of their rights and responsibilities. Pre-admission assessment processes are good, ensuring the home can meet the needs of potential residents. Further work is required to ensure prospective residents are informed about trial visits they can undertaken in order that they can be sure the home can meet their needs. EVIDENCE: The home has a statement of purpose and service user guide that is in pictorial and large print. Upon inspection of these documents the inspector found that further development is required to ensure prospective residents and their Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 10 representatives are given comprehensive information about the home and service provision. For example they do not make reference to any therapeutic techniques used in the home, the age range it is registered for, the qualifications and experience of the registered provider and detailed information regarding room sizes. The inspector was informed that a copy of the service users guide is issued with every admission pack. The inspector sampled 6 residents files (including one respite) and found that they all contained contracts/terms and conditions of residency and that the majority of these had been signed by either the resident or their representative and an agent of the home. In addition to this residents receive a letter of acceptance for admission prior to their arrival confirming that the home can meet the assessed, agreed needs. Residents are accepted for admission on the basis of a community care assessment and the homes own assessment undertaken by senior staff. Occasional emergency respite admissions are accepted on the assessment of the admitting Social Worker. When viewing assessments the inspector found that one resident needs have altered with records indicating that nursing care is now required. As the home is not registered for this service the inspector discussed this situation with the acting manager who explained that the social work team are in the process of looking for alternative accommodation but that no timescale for action had been given. The inspector explained that this was not acceptable and if allowed to continue for an indeterminate length of time would result in the home being in breach of its registration category. All staff that were interviewed demonstrated understanding of the importance of thorough assessments, for example one person explained, “these must be in place before someone moves in here so that we know what support people need with things like mobility, what they can do for themselves, what daily living tasks they need support with”. The home has a corporate policy and procedure for enquiries and referrals for service provision. Upon inspection of this document it was found to give instructions for staff but not information for prospective residents and their representatives in relation to trial visits. The inspector instructed that information regarding the range of visits that prospective residents can undertake be included in the service user guide. Details of initial contact and visits undertaken to the service were found to be recorded on contact sheets. The acting manager also stated that if representatives of the home visit prospective residents in their own home information is recorded in the preadmissions documentation. Intermediate care is not offered at this home; therefore this standard is not applicable. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 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): 8 and 11. Generally the health needs of residents are well managed. Further improvements in recordings will ensure these are appropriately monitored and met in full. Information given to residents and their representatives in relation to what support can be given to people who are seriously ill or dying is poor. Records must be maintained that demonstrate residents wishes with regards to illness and death are respected. EVIDENCE: Although standard 10 was not assessed at this inspection it is noted that a previous requirement relating to this standard is now met. Files that the inspector sampled all contained evidence that residents or their representative’s views have been sought in relation to personal care being given by someone of the opposite gender. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 12 The case files sampled by the inspector all contained information evidencing that residents have access to health care and are registered with a GP and receive the services of other allied medical professionals such as Dental, Ophthalmic, Nursing and Chiropody. None of the files sampled contained evidence that residents have the opportunity to access hearing tests. Residents are assessed for the risk of developing pressure sores, falls and manual handling with preventative measures put into place as needed. When examining health care records the inspector found that in the main these are completed in full but that some contained more information than others. For example one person had a dietary information sheet but this had not been completed, that the oral care sheet for another resident contained no information and that some residents are not being weighed on a monthly basis. When interviewing staff everyone demonstrated knowledge and understanding of their role in ensuring the health needs of residents are met. For example one person stated, “Because everyone has dementia we have a responsibility to look for signs such as changes in behaviour, not eating or becoming agitated. These might mean someone is unwell but cannot tell us”. On the day of inspection no written policy or guidance could be found in relation to care of the dying and wishes on death. The inspector instructed that information regarding this must be included in the service user guide in order that residents and their representatives are fully informed of services that can be provided by the home. In addition to this none of the 6 files sampled contained information regarding residents wishes in relation to funeral arrangements and belongings after death. The inspector was however informed that staff receive training in bereavement as part of the corporate induction that everyone undertakes. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 13 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): 13, 14 and 15. Opportunities to access the local community are poor, with little evidence that the home initiates off-site activities that could enrich resident’s lives. Generally residents are supported to exercise choice and control over their lives. Although improved further work is still required to ensure residents are able to exercise choice and control over what they eat and that cultural needs are catered for. EVIDENCE: A requirement identified in the September 2005 to ensure residents are given opportunities to access the local community on a regular basis remains unmet. Records viewed by the inspector evidenced that one outing to a local store had occurred in a two-month period. The acting manager confirmed that it is difficult for outings to be arranged as this would require additional staffing but recognised the benefit this would have to people living at the home. Residents are encouraged and assisted to arrive at choices about their daily routines such as choosing clothes, meals and activities. In addition to this residents are encouraged and supported to bring items of personal belonging Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 14 into the home on admittance, with all files sampled containing inventories detailing these items. All current residents are assisted in managing their financial affairs, with risk assessments in place that support decisions made to undertake this task. In order to give additional support to residents and their representatives the inspector instructed that information regarding advocacy services be included in the service user guide and that posters be displayed prominently around the home. Information regarding residents rights to access their personal records is however included in the service user guide, stating that a ‘formal’ application must be made if access is required. The inspector instructed that the home must define ‘formal’ to ensure resident’s rights are not compromised. A previous requirement to ensure residents receive varied, wholesome and nutritious meals, with records maintained is partly met. Since the last inspection advice has been sought from a dietician who has approved the menus at the home and staff now record meals taken at lunchtime. The inspector instructed that all meals must be recorded in order that effective monitoring can take place. The acting manager informed the inspector that a meeting had taken place with kitchen staff where specific religious and cultural meals were discussed and that these are going to be incorporated into menus. Once completed this will address a requirement identified in the September inspection. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 15 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 and 17. Staff have excellent knowledge of acting as advocates for residents to raise issues or concerns. Further development of complaint records is required to ensure concerns are acted upon appropriately. The rights and responsibilities of residents are well managed in this home. EVIDENCE: Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 16 The home uses the local authority Social Services Departments complaints, compliments and comments’ procedures, a copy of which was seen to be available, this containing clear timescales for response to complaints within a 28-day timescale. Information regarding residents rights to make complaints was also found in the service user guide, however both documents require amending as they do not inform people that they have the right to refer a complaint to the Commission for Social Care at any stage, should they wish to do so. Records viewed by the inspector detailed an abundance of compliments received by the home in relation to care and service provision and that no complaints have been received since March 2005. However when looking at the minutes from a staff meeting a number of complaints were raised by staff on behalf of residents. The inspector instructed that these must be recorded as formal complaints, with actions taken and outcomes documented. The majority of people living at the home are unable to raise issues or concerns on their own behalf due to conditions associated with dementia and the fact that staff are doing this demonstrates their understanding of their role in supporting residents. This understanding of their roles as advocates was further reinforced when interviewing staff, all of who demonstrated knowledge in this area. As one member of staff explained, “our role is to see to their needs, I’m here to look after them and if they cannot speak on their own behalf I must do this”. The inspector was informed that the electoral roll is completed and residents supported to exercise their rights in relation to voting, with one resident escorted to a local polling station at the last election. In addition to this postal voting is also arranged by the home. Although not standard 18 was not assessed in full at this inspection it was noted by the inspector that since the last inspection 98 of the workforce have undertaken adult protection training and the contents of the whist blowing policy were discussed with staff in the October supervisions, addressing requirements identified in September 2005. A rolling programme for dementia has also started that includes physical aggression training partly meeting a previous requirement. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 17 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 and 26. The standard of the environment within this home is adequate, providing residents with a comfortable place to live. Health and safety matters relating to the environment although improved, still require attention to ensure it is a safe place for people to live. EVIDENCE: Progression has been made to address requirements made by the fire and environmental health departments with only a few issues now requiring attention. In addition to this many areas of the home have been redecorated and bedrooms continue to be provided with double electrical sockets as and when they become vacant. The acting manager stated that the water temperatures for sinks are regularly monitored with remedial action taken if excessive. The inspector sampled 8 water outlets and found all but one to be safe. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 18 Since the last inspection advice has been sought from an infection control specialist with regards to the use and cleaning of commodes (addressing a previous requirement). Recommendations are being investigated by the home in order that it can improve infection control standards. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 19 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 and 30. Improvements to staffing have taken place, resulting in greater protection for residents. Further work must be undertaken to ensure staff receive the appropriate training in order to fulfil their roles and to meet the needs of residents. Staff records are poor and do not demonstrate residents are protected by the homes recruitment and selection procedures. EVIDENCE: Previous requirements to ensure kitchen staff are employed in sufficient numbers and that a member of staff is always deployed in any of the lounges where residents are located are now met. The inspector witnessed a marked improvement in the deployment of staff and everyone that she spoke to confirmed their understanding of their responsibilities in this area. Recruitment is undertaken in line with the local authorities equal opportunities policy and monitored by Human Resource department, which retains the staff files centrally with a copy file held locally. Upon inspection of 3 staff files none were found to contain all required information as listed in Schedules 2 and 4 of the Care Homes Regulations 2001. Items missing included photographs, job descriptions and forms of identification. The home uses a profoma that details reference numbers for CRB disclosures however this needs further Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 20 development to also demonstrate POVA checks have also been undertaken. As one member of staff stated when being interviewed, “there are some very vulnerable people here, so recruitment practices must safeguard people from abuse”. The homes policy for the use of volunteers also requires amending, as presently this makes no reference to the requirement of CRB/POVA disclosures. A discussion took place between the acting manager and the inspector in relation to the retention of staff documentation, with information supplied to the home regarding the commissions approved proforma and applications required for its use. There are presently thirty care staff employed at the home, thirteen of who hold a national vocation qualification at level 2 or 3, with two other staff in the process of completing this qualification. Verification of numbers of regular agency staff who hold this qualification could not be gained, as records were incomplete. A requirement to ensure all staff receive training specific to the needs of people with dementia is partly met. The acting manager stated that a rolling programme has been introduced where 4 or 5 staff undertake modules of learning for dementia and that topics such as prevention of falls and tissue viability form part the corporate induction (no records were available on the day of inspection to verify this). Records viewed and discussions with staff indicate that staff are restricted in terms of training they can undertake due to insufficient places available on training provided by the local authority. Presently training is managed centrally with the home having no control over allocation of places resulting in a proportion of the workforce being unqualified. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 21 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, 32, 33, 35, 36, 37 and 38. The acting manager encourages involvement and communication, creating a positive and inclusive atmosphere within the home. An application to register a manager must be submitted to ensure staff moral does not deteriorate. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of residents and other stakeholders. The homes practices in relation to management of resident’s finances are good, protecting those that live at the home. Improvements to staff supervision now support them to carry out their roles and responsibilities effectively. Generally records maintained in the home ensure the protection of vulnerable adults. Further work is still required to ensure training is provided to staff. Without this the health, safety and welfare of residents could be compromised. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 22 EVIDENCE: A previous requirement for an application to register a manager for the home remains unmet. There has been no registered manager at the home for over a year, with the acting manager being in post since November 2005 (her substantive post is at another local authority establishment). The acting manager holds national vocational qualifications level 3 and 4 and the registered managers award and observations throughout the inspection demonstrate competence as a manager of an older persons establishment. The inspector instructed that the local authority must make a decision with regards to employing a permanent manager for the home and submit an application for registration as a matter of priority. An abundance of compliments were received about the acting manager and the support she has given to staff, for example one person stated, “its been much better since she has been here, she has sorted a lot of things out and given us support. Before she came we were just muddling along. We just worry now about the future”. Also since the acting manager has been in post she has reorganised the corporate quality assurance system with evidence that this is now incorporated into all aspects of service provision. A range of quality assurance audits are undertaken including service user satisfaction surveys, external quarterly audits, random checks by the acting manager, regular monitoring of staff support and residents care packages. All information gained is then analysed and incorporated into an annual report that is linked to the business objectives for the service. The inspector was pleased to find that the majority of staff that were interviewed understood the importance of a quality assurance system, giving examples such as, “its monitoring to ensure everything is carried out to a good standard”. The systems for managing resident’s finances were scrutinised and found to be in order. Individual records are maintained of personal allowances held on behalf residents along with corresponding receipts. In addition to this safe checks are completed on every shift adding further protection to those living at the home. The inspector was pleased to find that since the acting manager has been in post regular, formal supervision has been reinstated for all staff. Schedules were viewed that demonstrate staff should receive monthly one to one supervision in addition to regular staff meetings. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 23 A marked improvement was also found to have taken place in relation to records required by regulation. Those that were inspected were found to be maintained in an orderly fashion, up to date and secure. It was noted and acknowledged by the acting manager that photographs for some residents are required. A previous requirement to ensure all staff undertake first aid, moving and handling, infection control, food hygiene and fire training is partly met, with work still required to ensure sufficient numbers of staff undertake infection control and fire training. Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 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 2 3 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 X 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 2 18 X 2 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 4 X 3 2 2 2 Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 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 Standard OP1 Regulation 4,5,6 Requirement The statement of purpose must include all information as listed in Schedule 1 of the Care Homes Regulations 2001. The service user guide must include all information as detailed in Regulation 5 of the Care Homes Regulations 2001. The resident and/or their representative and an agent of the home must sign all contracts/terms and conditions of residency. The home must not provide placements for anyone who is assessed as requiring nursing care. Information regarding the range of trial visits to the home must be included in the service user guide. All residents must be given the opportunity to access hearing tests, with records maintained. Comprehensive health care records must be maintained for all residents. Timescale for action 31/05/06 2 OP1 4,5,6 31/05/06 3 OP2 5(1) 31/05/06 4 OP4 14(1) 12/02/06 5 OP5 12(2) 31/05/06 6 OP8 12(1) 31/03/06 Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 26 7 OP11 12(1) All residents must be weighed on a regular basis, with records maintained. A written policy for care of the dying and how this may impact on service users residency at the home must be introduced and included in the service user guide. Resident’s wishes in relation to funeral arrangements and belongings after death must be sought, with records maintained. Service users must be given the opportunity to access the local community on a regular basis – Requirement originally made September 2005. Advocacy details must be included in the service user guide and displayed prominently throughout the home. CSCI must be supplied with a written explanation that defines ‘formal’ applications to access resident’s records as detailed in the service user guide. The home must ensure service users receive a varied, wholesome and nutritious meals, with records maintained – Part met. Requirement originally made September 2005. The religious or cultural dietary needs of service users must be met – Requirement originally made September 2005. The homes complaints procedures and information contained within the service user guide must be amended to inform people that they have the right to refer a complaint to CSCI at any stage should they wish to do so. DS0000034140.V281533.R01.S.doc 31/05/06 8 OP13 12(4) 31/03/06 9 OP14 12(3) 31/05/06 10 OP15 16(2) 31/03/06 11 OP16 22(1) 31/05/06 Grafton Lodge Version 5.1 Page 27 12 OP18 10(1) 13 OP19 16(1) 14 OP19 16(1) 15 OP19 16(1) 16 OP24 23(2) 17 OP26 13(3) 18 OP28 18(1) 19 OP29 19 A record of all issues/complaints raised by staff on behalf of residents must be maintained, including actions taken and outcomes. All staff (including regular agency staff) must undertake physical aggression training, with certificates maintained at the home – Part met. Requirement originally made September 2005. Both kitchen servaries must be cleaned and redecorated – Part met. Requirement originally made September 2005. The home must address all requirements made by the Fire Department – Part met. Requirement originally made September 2005. The home must address all requirements made by the Environmental Health Department – Part met. Requirement originally made September 2005. The responsible person must provide a second double electric socket in service users bedrooms – Part met. Requirement originally made August 2004. The responsible person must ensure that staff are able to practice good hand washing under safe hot running water – Part met. Requirement originally made February 2005. All staff (including regular agency staff) must hold an NVQ level 2 or equivalent, or be working towards this. Records must be maintained for all staff (including regular agency staff) as listed in Schedules 2 and 4 of the Care DS0000034140.V281533.R01.S.doc 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 12/02/06 31/05/06 31/03/06 Grafton Lodge Version 5.1 Page 28 Homes Regulations 2001 or An application for an agreed proforma to be implemented that contains all required information by legislation must be submitted to CSCI. The written policy for volunteers must be amended to make reference to the requirement of CRB/POVA disclosures. All staff (including regular agency staff) must undertake continence management, prevention of falls, dementia care and tissue viability, with certificates maintained in the home – Part met. Requirement originally made September 2005. An application to register a manager must be made to the Commission for Social Care Inspection – Requirement originally made September 2005. The registered person must ensure that staff receive a minimum of six supervisions each year and devise a plan to demonstrate how this will be delivered – Part met. Requirement originally made February 2005. A photograph of each resident must be retained on his or her file. All staff must undertake first aid, moving and handling, infection control, food hygiene and fire training, with certificates maintained in the home – Part met. Requirement originally made September 2005. 20 OP30 18(1) 31/05/06 21 OP31 9 31/03/06 22 OP36 18(2) 31/05/06 23 24 OP37 OP38 17 13(3) 31/05/06 31/05/06 Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 29 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 OP7 Good Practice Recommendations It is recommended that a more in-depth assessment of falls be undertaken using a recognised assessment tool – Part met. Recommendation originally made February 2005. It is recommended that a more in-depth assessments for self-medicating be introduced based on each persons capabilities – Part met. Recommendation originally made September 2005. A number of double glazing units show signs of having failed and should be replaced in a timely way – Recommendation originally made August 2004. It is recommended that a sluice disinfector be provided to avoid the need to chemically disinfect commodes – Recommendation originally made February 2005. 2. OP9 3. 4. OP19 OP26 Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Grafton Lodge DS0000034140.V281533.R01.S.doc Version 5.1 Page 31 - 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. 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