Inspection on 09/09/05 for Grafton Lodge

This inspection was carried out on 9th September 2005.

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 11/02/06

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 9 September 2005 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 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 E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Grafton Lodge Address Grafton Road Oldbury West Midlands. B68 8BJ 0121 559 3889 0121 559 0708 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sandwell MBC Care Home 36 Category(ies) of DE(E) Dementia - over 65 registration, with number of places Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: All requirements contained within the pre-registration report of 13 January 2003 are met within the timescales within the action plan agreed between Sandwell Metropolitan Borough Council and the Commission for Social Care Inspection. Day care provision must not encroach on the facilities, staffing and services provided to residential service users. Date of last inspection 2nd February 2005 Brief Description of the Service: Grafton Lodge is owned by Sandwell Metropolitian 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 availible at Grafton Lodge, which are detailed in the homes Servicer User Guide. Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 9.50am and stayed at the home until 7.30pm. Due to all the service users who live at the home having moderate to severe forms of dementia the inspector was unable to have constructive discussions with them to find out their views and opinions on service provision and therefore spent three and a half hours formally interviewing staff and one and a half hours observing care practices in order to assess how the home is meeting its aims and objectives. In addition to this time was spent talking to the manager and looking at records before giving feedback on the inspection process. Since the last inspection (February 2005) a new manager has been appointed who previously worked within another home owned by Sandwell Metropolitan Borough Council. During the inspection the manager agreed to submit an application for registration to the Commission For Social Care Inspection by October 2005. By the end of the visit the inspector was satisfied that in general the home offers a good service and would like to thank everyone for his or her cooperation and assistance during the day. What the service does well: When asking staff what is the best thing about working at the home everyone who was interviewed made comments relating to the service users. Examples included, “It’s a very rewarding job, when you see residents smile and know you have caused it” and “The feel good factor. I get a kick out of knowing I have helped someone”. The inspector found these comments to reflect practices within the home where residents are encouraged and supported with all their care needs and positive relationships have been formed between staff and residents. The inspector also found that care planning processes within the home are very good, ensuring that staff who work at Grafton Lodge have sufficient information in order to meet the needs of service users. Staff should be congratulated for their efforts to ensure positive relationships are maintained between themselves and the people living at the home despite Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 6 service users having moderate to severe levels of dementia. Throughout the visit the inspector witnessed staff making eye contact, looking for facial gestures and body language in order that service users wishes could be obtained. In-house activities are managed in a way as to offer choice and variation to the people who live at Grafton Lodge. What has improved since the last inspection? What they could do better: Further work must be undertaken to ensure all staff attend training specific to the needs of the residents, including dementia care, continence management and adult protection. These training requirements must be given priority in order that the staff skills and knowledge complements the needs of the people living at the home. Priority must also be given to ensuring mandatory training such as fire, first aid and food hygiene is undertaken by all staff to ensure service users health and safety is maintained. Systems for recording and evidencing that service users receive a choice of nutritious and appealing meals must be improved. Presently no records are maintained in this area that demonstrate choice or that the needs of people from varying cultural backgrounds are being met. Staffing levels generally are maintained to an acceptable level, but must be monitored to ensure they are deployed appropriately throughout the building to ensure service users are not placed at risk. Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 7 Advice must be sought from the Infection Control Advisor regarding the homes practices for sanitising commodes, to ensure they comply with legal requirements. Further improvements to the building must also take place to make sure the home is safe and comfortable for the people who live there. Management must ensure staff receive the appropriate levels of supervision, as this Requirement remains outstanding from previous inspections. 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 E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 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 standard(s) Standards not assessed at this inspection. EVIDENCE: Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7, 9 and 10. There are clear and consistent care planning systems in place that adequately provide staff with the information they need to satisfactorily meet service users needs. The medication at this home is well managed promoting good health. Generally personal support in this home is offered in such a way as to promote and protect service users privacy, dignity and independence. EVIDENCE: The inspector interviewed 4 members of staff, all of whom could explain aims or goals detailed in service users plans of care, when they are reviewed and by whom. In addition to this staff confirmed their understanding of the key worker role. For example one member of staff stated, “as a key worker I am responsible for ensuring clients have the right clothes, monitoring their health, maintaining their room and making sure their personal care takes place”. All care plans that were sampled contained assessments for the prevention of falls (a previous recommendation to extend the content remains outstanding), continence, pressure sore management and moving and handling. Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 11 Staff interviewed also confirmed that no one living at the home self medicates due to everyone having varying levels of dementia. Records viewed by the inspector confirmed that risk assessments were in place for this practice, however the inspector recommended they be extended in terms of content and context. Throughout the inspection staff were observed treating service users with dignity and respecting their rights to privacy. For example staff were witnessed knocking on bedroom and bathroom doors before entering and talking in a respectful manner to service users. These practices were further reinforced as the norm by staff when interviewed. For example one person stated, “its important to listen to what residents have to say, to be sure they want my help and to act on their wishes” and another said, “I always like to talk to residents to find out their feelings, even if someone has communication problems I never assume they have not got feelings”. All the service users at Grafton Lodge have differing levels of dementia, however staff were still witnessed asking their opinions, talking in a calm and reassuring manner and checking for consent before completing care tasks. The inspector witnessed service users being assisted with personal care by staff of the opposite sex despite staff of the same gender being on duty. When looking at records the inspector could find no evidence of consent or that service users and/or their representatives had been made aware of this practice. Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12, 13 and 15. In-house activities are good, providing daily variation and interest for people living in the home. Opportunities to access the community are poor, with little evidence that the home initiates off-site activities that could enrich service users lives. The atmosphere within the home is welcoming and inclusive, which supports service users to maintain contact with their families. The choice of meals and drinks in this home are poor, with little evidence that service users are able to exercise choice and control over their diet/what they eat. EVIDENCE: All staff interviewed confirmed that service users are offered a variety of activities. For example one person stated, “we hold reminiscence sessions, board games, music and dance and walks in the garden”. The manager also stated that an artist visits one service user after it was identified that they enjoyed this activity. When asking staff if service users go out in the local community, again staff confirmed that they do but comments were made about the frequency. For example, “we take them out on the bus sometimes but not very often because there not enough staff”. These comments were validated by records viewed by the inspector, which indicated activities take Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 13 place within the home on a daily basis but that only one outing into the community has taken place in a five-month period. The manager confirmed that although activities take place further work in this area is required. When asking staff how they support service users to maintain links with their families a variety of examples were given including, “we ring families on the behalf of service users and show service users photographs of their family members” and “a lot of families visit on a regular basis and we keep them informed about their relative. Its important that families feel happy about the care their relative receives”. Visitors that the inspector spoke to confirmed that they are made welcome and kept informed about their relative’s care and wellbeing. The inspector was unable to fully assess if service users are provided with varied and nutritious meals as presently the home does not maintain any records of meals offered or taken (apart from a menu that is displayed on a wipe board each day then erased). Three of the four staff interviewed commented on the lack of choice for the evening meals, for example one person stated, “its sandwiches for tea every day” and another “there’s not enough choice and variety”. When looking at staffing records the inspector found that when kitchen staff take annual leave the shifts are not being covered resulting in no staff from 2.30pm. The inspector feels that this practice is affecting the provision of meals to service users. Also the inspector could find no evidence of specific dietary and cultural needs being met despite service users from differing cultural backgrounds residing at the home. When observing care practices the inspector witnessed staff bringing afternoon drinks to the service users. Staff were witnessed offering a cup of tea only and putting milk and two sugars in everyone’s drink; further evidence of the lack of choice for service users. Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 18. Staff’s knowledge of adult protection is poor, potentially leaving service users at risk of abuse. EVIDENCE: There have been two potential adult protection issues since the home was last inspected, both of which have been acted upon appropriately by the home, including reporting to the Commission for Social Care Inspection. When asking staff how they ensure service users are protected from abuse all staff explained how abuse could occur between service users. For example one person stated, “ we have to watch service users all the time. Some service users can be rough towards other service users so we have to sit with them or separate them if they become violent”. When asked what they would do if they thought they witnessed a member of staff abusing a service user responses varied. The inspector was concerned that some staff said that they would not report bad practice unless they were “a hundred percent sure” of what they had seen. No staff that were interviewed demonstrated sufficient knowledge and understanding of adult protection. Staff confirmed that they discuss adult protection as part of the induction programme, but that they had not undertake further training in this area (apart from one person who was provided training by another organisation) since commencing employment. Training records for the staff that were interviewed validated these comments, with none containing evidence of Adult Protection or Physical Aggression training. It was also noted by the inspector that none of the staff that were interviewed knew of the Whistle blowing policy. When discussing this with the manager he agreed that the Whistle blowing policy was an important policy that staff should be aware of and explained systems he had put in place at the Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 15 establishment he previously managed, which he stated would be introduced at Grafton Lodge. Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19, 24 and 26. Limited improvements to the décor have been made. The outstanding matters do not provide the people living in the home with safe, comfortable surroundings. EVIDENCE: Previous Requirements to install a second double electric socket in service users bedrooms and to ensure staff are able to practice good hand washing under safe hot running water remain outstanding. The manager did explain that double sockets were being fitted as and when rooms become vacant but at present only 5 rooms have been actioned. Also the manager said that all sinks now have signs warning of the dangers of hot water, however due to the excess temperatures these still do not allow for effective hand washing. After touring the building the inspector found that in general the home is maintained to an acceptable standard. However attention must be given to: Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 17 * Cleaning and decorating both serveries (paying particular attention to sink areas) to ensure environmental health standards are maintained. * Clarifying if the fridges in the serveries are used for staff. Appropriate labelling and storage must be maintained to ensure food safety standards are maintained. The bin that is used in the bathroom on South wing for continence pads requires a lid to ensure infection control standards are maintained. * The cracks that running down the walls near the 1st floor by the lift must be investigated to ensure the building is structurally safe. * Arrangements must be made for the repair of the ceiling that was damaged by leaking water to ensure the décor of the building is maintained to a satisfactory standard. * Some of the garden benches require re-staining as they are looking very worn and old. * The build up of lint behind the dryers in the laundry must be removed to ensure fire safety standards are maintained. A previous recommendation to provide a sluice disinfector has not been actioned. The inspector was informed by staff and the manager that the current practice for cleaning commodes consists of a bucket of sterilising fluid being taken around the building, with commodes being cleaned in it. The inspector instructed that the home must arrange for the Infection Control Advisor to visit the home, give advise on current practices and implement any requirements that are made. The Fire Department visited the home on 23 August 2005 and made 8 requirements, with a further inspection due on 15 September 2005. The inspector was shown an action plan by the manager that included timescales for compliance to meet the requirements, however on the day of inspection 5 of the requirements remained outstanding. The Environmental Health Department inspected the home on 18 March 2005 with all but one of the 12 requirements identified within this visit being actioned. Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30. There are sufficient staff on duty to meet the needs of service users, but the deployment of staff throughout the building does not ensure the safety of service users is maintained at all times. Training provided by the home for staff in relation to the needs of older people is poor, resulting in some staff not having the appropriate knowledge to meet the needs of service users. EVIDENCE: Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 19 Records confirmed that the home deploys three care staff on each unit from 7.30am until 10.00pm and one waking night person along with a ‘floating’ night worker who works between both units. In addition to this kitchen and domestic staff are employed seven days a week. Through discussions with staff and looking at rotas the inspector found that there have been several occasions when the kitchen staff have not been maintained to their full compliment, usually when annual leave is taken, resulting in a deterioration in choice of meals prepared (see Standard 15). The inspector also spent time sitting in the lounge areas observing care practices and was concerned that for a twenty minute period (apart from two separate one minute intervals) between eight and eleven service users were left unattended, despite staff confirming that due to the levels of dementia service users must never be left by themselves. When feeding back to the manager about this observation he agreed that this was unacceptable and would be addressing it with the staff concerned. After analysing training records the inspector felt that further work must be undertaken to ensure staff are trained in areas specific to older people such as continence management, prevention of falls, dementia care and tissue viability. The manager recognises that improvements to staff training must be made and informed the inspector that discussions within the local authority relating to this were in process. Staff interviewed confirmed that these subjects form part of the induction process but depending on the length of time a person has been employed training could have occurred several years ago. It was also brought to the inspector’s attention that eight staff have recently been deployed to the home from another local authority home that recently closed. The home that closed did not offer care for people with moderate to severe dementia and the majority of the staff have not undertaken training in this subject. The inspector also instructed that agency staff who undertake regular shifts at the home must be offered the same training as those employed by the local authority to ensure consistent care is give to the people who live at Grafton Lodge. Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36 and 38. The manager has a good understanding of the areas in which the home needs to improve, indicating how this was going to be managed to improve service provision throughout the home. Training provided to staff is poor. This results in some practices that do not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: As mentioned in the summary of this report a new manager, Mr Paul Paxton took up post at Grafton Lodge in April 2005. Previous to this Mr Paxton was the registered manager of another older persons establishment owned by Sandwell Metropolitan Borough Council and has several years experience of management of care services. Mr Paxton agreed to supply an application for registration to the Commission for Social Care Inspection by October 2005. Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 21 A Requirement to ensure staff receive a minimum of six supervision sessions a year remains outstanding. The manager stated that group supervision was provided in the form of staff meetings but as yet the target for individual supervisions has yet to be actioned. Improvements must be made in relation to staff training in first aid, moving and handling, infection control, food hygiene and fire. The inspector sampled four staff files none of which contained evidence that staff held up to date certificates in all of these mandatory training requirements. The lack of appropriate training was further reinforced when the inspector witnessed a member of staff attempting to assist a service user to put their slippers on. The member of staff found this task difficult as the service user was sitting in a chair yet the member of staff did not bend down at the knee, instead leaned over from the waist. Eventually after five minutes of attempting to complete this task the member of staff kneeled down and was able to accomplish what they had been attempting to achieve. When discussing training with the manager he confirmed that training was a need that he had already identified and that discussions with senior management within the local authority had taken place regarding this. Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 x 15 1 COMPLAINTS AND PROTECTION 2 x x x x 2 x 2 STAFFING Standard No Score 27 2 28 x 29 x 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 2 x x x x 2 x 2 Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 23 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 OP10 Regulation 12(4) Requirement Timescale for action 31/12/05 2. 3. OP13 OP15 12(4) 16(2) 4. OP18 10(1) Service users and/or their representatives consent must be sought for personal care to be given by someone of the opposite sex Service users must be given the 31/12/05 opportunity to access the local community on a regular basis 31/12/05 The home must ensure service users receive a varied, wholesome and nutritious meals, with records maintained. Service users must be offered three full meals each day (at least one of which must be cooked) at intervals of not more than five hours. Hot and cold drinks and snacks must be available at all times and offered regulary. Special therapeutic diets must be provided, including adequate provision of clacium and vitamin D. The religious or cultural dietary needs of service users must be met. All staff (including regular 31/12/05 agency staff) must undertake adult protection training, with certificates maintained at the Version 1.40 Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Page 24 home 5. OP18 10(1) All staff (including regular agency staff) must undertake physical aggression training, with certificates maintained at the home The home must ensure staff are aware of the contents of the Whistleblowing policy The cracks that run down the walls near the 1st floor by the lift must be investigated. The ceiling that has water damage must be repaired. Both kitchen serveries must be cleaned and redecorated. Food must be appropriately stored and labelled in the kitchen servery fridges The worn garden furniture must be repaired or replaced The home must address all requirements made by the Fire Department The home must address all requirements made by the Environmental Health Department The responsible person must provide a second double electric socket in service users bedrooms (REQUIREMENT ORIGINALLY MADE AUGUST 2004) The responsible person must ensure that staff are able to practice good handwashing under safe hot running water (REQUIREMENT ORIGINALLY MADE FEBRUARY 2005) The home must arrange for the Infection Control Advisor to visit the home and give advise on current practices in relation to the cleaning of commodes and implement and requirements made All bins in bathrooms used to 31/12/05 6. 7. OP18 OP19 10(1) 16(1) 31/12/05 31/12/05 8. OP19 16(1) 31/12/05 9. 10. 11. OP19 OP19 OP19 16(1) 16(1) 16(1) 31/12/05 31/12/05 31/12/05 12. OP24 23(2) 31/12/05 13. OP26 13(3) 31/12/05 14. OP26 13(3) 31/12/05 15. OP26 13(3) 31/12/05 Page 25 Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 16. OP27 18(1) 17. OP27 18(1) 18. OP30 18(1) 19. OP31 9 20. OP36 18(2) 21. OP38 13(3) store soiled continence items must have lids. The build up of lint behind the dryers must be removed. Kitchen staff must be employed in sufficient numbers to ensure that standards relating to the choice of meals are maintained at all times A member of staff must always be deployed in each of the main lounges when service users are in residence All staff (including regular agency staff) must undertake continence management, prevention of falls, dementia care and tissue viability, with certificates maintained in the home An application to register the manager must be made to the Commission for Social Care Inspection 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 (REQUIREMENT ORIGINALLY MADE FEBRUARY 2005) All staff must undertake first aid, moving and handling, infection control, food hygiene and fire training, with certificates maintained in the home 31/12/05 Immediate 31/12/05 01/10/05 31/12/05 31/12/05 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 indepth assessment of falls E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 26 Grafton Lodge 2. 3. 4. OP9 OP19 OP26 be undertaken using a recognised assessment tool (RECOMMENDATION ORIGINALLY MADE FEBRUARY 2005) It is recommended that a more indepth assessments for self medicating be introduced based on each persons capabilities 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)h Grafton Lodge E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. 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 E55 S34140 Grafton Lodge V248783 090905 Stage 4.doc Version 1.40 Page 28 - 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!