Inspection on 02/05/06 for Grange Cottage Residential Home

This inspection was carried out on 2nd May 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

Grange Cottage Residential Home 07/04/09

Grange Cottage Residential Home 29/04/08

Grange Cottage Residential Home 07/11/07

Grange Cottage Residential Home 15/09/05

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

CARE HOMES FOR OLDER PEOPLE Grange Cottage Residential Home 6 Grange Road Sutton Surrey SM2 6RT Lead Inspector Mohammad Peerbux Key Unannounced Inspection 2nd May 2006 9:40am 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 Grange Cottage Residential Home DS0000061844.V291713.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. Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grange Cottage Residential Home Address 6 Grange Road Sutton Surrey SM2 6RT 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) 020 8642 2721 020 8642 2721 NO EMAIL Grange Cottage Residential Home Mrs Vijayantimala Halkoree Mr Derek Read Care Home 11 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0) Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow four specified service users under the age of 65 to be accommodated until such time that the home is unable to meet their assessed needs or their placement terminates. 15th September 2005 Date of last inspection Brief Description of the Service: Grange Cottage is a small residential home registered for eleven service users over the age of 65, who suffer from long-term mental health problems including dementia. Four service users are under the age of 65 and variations of registration have been issued for them. The accommodation is provided over two floors; there is no lift however all the service users are able to use the stairs. There are nine single bedrooms and one shared room. All the bedrooms have washbasins. There is parking to the front of the property and a pleasant garden to the rear. The home is well served by public transport routes. The range of weekly fees is between £400 and £450 and this information was gathered on the day of the inspection (02/05/06). Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection for the year 2006/07. It was an unannounced inspection and took place over five hours. Some times were spent looking at the policies and procedures, talking to staff, manager and to some of the service users. A tour of the building was also carried out. Service users spoken to stated that they were happy with the care being provided. Overall the inspection confirmed that the home provides a good level of care for the service users who live there. What the service does well: What has improved since the last inspection? The providers have successfully managed to address well over half the outstanding requirements identified in the services last inspection report and made some progress to meet several others. The providers’ comment that significant progress has been made in the past year to rectify many of the services shortfalls is acknowledged by the Commission. Medication administration sheets sampled at random were all error free .All staff have attended medication training. The service users and/or their relatives have been consulted about their last wishes and these are documented in their personal files. The complaints procedure has been amended to include the stages and timescales for response. The quality assurance surveys have been extended from service users, relatives and friends to include visiting professionals and any other stakeholders. Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 6 What they could do better: The home’s statement of purpose and service users guide both need to be revised to contain more detailed information about staff qualifications to enable prospective service users and their representatives to make informed decisions about whether or not to use this service. All service users must have a plan in place that sets out in detail the action which needs to be taken by care staff to ensure that all their aspects of the health, personal and social care needs are met. They must be drawn up after consultation with the service user, family, friends and an advocate where appropriate. Service users’ care plans need to be reviewed and updated by care staff in the home at least once a month, to reflect changing needs and current objectives for health and personal care, and actioned. The procedure for responding to suspicion or evidence of abuse or neglect must be amended to state that any abuse will be investigated by Care Management Team and not by the person in charge. Written guidelines need to be in place on how to deal with the service user who can be physically aggressive.This must be discussed with the service users and their relatives. The home must have a staff training and development programme in place that meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. Staff also need to be supervised on a regular basis .The manager must apply to the Commission to become the registered manager for the home and must achieve NVQ4 in management and care. An annual QA Development Plan must be produced. This should include feedback from the surveys and assess the extent to which the home’s aims and objectives are being met. The registered person needs to ensure so far as is reasonably practicable the health, safety and welfare of service users and staff are promoted and protected at all times. It is recommended that the service user’s guide and care plans are made available in a language and/or format suitable for intended service users. It is also recommended that the activities timetable is displayed on the notice board and it is circulated to all service users in formats suited to their capacities. Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 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. Grange Cottage Residential Home DS0000061844.V291713.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 Grange Cottage Residential Home DS0000061844.V291713.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): 1,3 and 6 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Changes are needed to both the Service Users Guide and the Statement of Purpose so that they accurately provide full information about the services. This will provide the correct information to enable people to make informed decision about the home on whether it will meet their needs. The home has its own assessment plan to ensure that any new service user’s needs are fully assessed prior to their admission. EVIDENCE: It was previously required that the registered person must produce and make available to service users an up-to-date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users’ guide to the home for current and prospective service users. The registered person has reviewed both documents however some information are still missing and/or out of date Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 10 and therefore this requirement would be repeated. The registered provider is reminded that the statement of purpose and service user’s guide must be a freestanding document or set of documents. It is not sufficient to be told that the required material can be found in various other places or via crossreferences. The service user’s guide and the statement of purpose should also be kept under review by the registered person and be revised should any changes to the service occur. It is recommended that the service user’s guide is made available in a language and/or format suitable for intended service users. Service users are only admitted to the home after a full assessment of their needs has been carried out by the home and the Placing Authority for individuals referred through Care Management, involving the prospective service user/recognised representative. Since the last inspection there has been a new service user who has been admitted to the home and it was noted that the home carried out a comprehensive needs assessment. However there was no plan of care in place for daily living, and longer-term outcomes, based on the Care Management assessment and Care Plan or on the home’s own needs assessment (see Standard 7, Service User Plan). The provider stated that he has drawn up a care plan however this was not available on the day of inspection. The home does not offer intermediate care. Grange Cottage Residential Home DS0000061844.V291713.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): 7,8,9,10 and 11 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ health, personal and social care needs are not being appropriately met as their care plans are not being reviewed and updated to reflect their changing needs. Service users are treated with respect and have their privacy respected. EVIDENCE: Three service users’ care plans were sampled, it was noted that they were not all up to date and not well maintained. They were not being reviewed or updated on a monthly basis to reflect the changing needs and current objectives for health and personal care of service users. This was a requirement made at the last inspection and would therefore be repeated. It was also noted that the new service user did not have a care plan in place so it would be difficult for staff to meet his health, personal and social care needs. The registered person must ensure that all service users have a plan in place that sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 12 service user (see Standard 3) are met. The registered person must also ensure that service users care plans are drawn up after consultation with the service user, family, friends and an advocate where appropriate. It is recommended that the care plan is made available in a language and format that the service user can understand and is held by the service user unless there are clear and recorded reasons not to do so. The service users’ risk assessment were also sampled and it was noted that they were not comprehensive and there were no date when they were drawn up or any review date. This might have an impact on the care being provided. The registered person must ensure that service users’ risk assessments are kept up to date and reviewed on regular basis and give details to what action is required to minimise identified risks and hazards. Again they must be drawn up with the involvement of the service user and recorded in a style accessible to the service user; agreed and signed by the service user whenever capable and/or representative (if any). The registered person was able to demonstrate, through individualised healthcare records, that service users are in regular contact with General Practitioners and other health care specialists as required. The home also keeps records of all the service users healthcare appointments, in addition to individual daily progress notes. The manager stated that the staff maintain the personal hygiene of each service user and, wherever possible, support the service user’s own capacity for self-care. The home has also access to professional advice about the promotion of continence. In general, medication records, including medicines received, administered and returned were all being appropriately maintained. The registered person has met all the requirements made at the last inspection with regards to medication. One of the service users self medicate and it was positively noted that she has a risk assessment in place. All staff have had refresher training in handling and administration of medication to service users. Observation of the staff team interacting with the service users showed that the carers were mindful how they addressed service users, and they were seen to be polite and friendly. The registered person stated that all new members of staff receive a structured induction that includes specific training in how to treat service users with respect and dignity at all times. It was previously required that the registered person must ensure that wishes of service users regarding death and dying, with appropriate support and involvement of other stakeholders, are recorded. These are now in place .It was also noted that as part of the admission process service users wishes regarding arrangements after death are now discussed and recorded. Grange Cottage Residential Home DS0000061844.V291713.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): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The daily routines and house rules promote service users’ rights, and ensure equality and that all rights are enjoyed by service users. Service users are well supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Service users are evidenced as being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and spiritual needs. The activities timetable is now displayed on the notice board in line with a recommendation made at the last inspection. However the activities timetable is still not being circulated to all service users in formats suited to their capacities and therefore this recommendation would be repeated. One of the service users goes to church on a daily basis and some of the service users receive the Holy Communion every Friday. Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 14 Service users are encouraged to maintain contact with friends and relatives and to develop links with the local community. Service users are able to receive visitors in private and are able to choose whom they want to see or not to see. The home has some responsibility for small amounts of money held for three service users. Records were seen to be accurate and well maintained. Service users are encouraged to bring personal possessions with them when they move into the home and these were seen in their bedrooms. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. The menus offer a choice of meals, and when the published menu options are not desired on the day, alternatives are offered. One of the service users is allergic to fish; the registered person has ensured that his dietary need is catered for. Grange Cottage Residential Home DS0000061844.V291713.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 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. However the home’s policies and procedures on abuse need amending to ensure that service users feel safe and protected. EVIDENCE: The home has a complaints procedure that is conspicuously displayed in the home for all to view. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The current complaints procedure is good and gives a clear step-by-step guide of how to make a complaint however it is only available in written format. It is recommended that the home’s complaints procedure is made available an appropriate language/format and is given and/or explained to each service user. The Commission has recently received an anonymous letter of concerns about the proprietor of the home and this is currently being investigated. The home has in place procedures for responding to suspicion or evidence of abuse, including whistle blowing, and passing on concerns to the Commission For Social Care Inspection. However the procedure must be amended to state that any abuse will be investigated by Care Management Team and not by the person in charge. The manager stated that only some of the staff team have had training in Abuse Awareness. The manager must make suitable Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 16 arrangements by training all staff to prevent service user’s being harmed or suffering abuse or being placed at risk of harm and/or abuse. The manager assured that no allegations or incidents of abuse had occurred in the home, but if they did the appropriate authorities would be informed and any action taken would be recorded. There is one service user who could be physically aggressive at times. The manager was required to ensure that written guidelines were in place on how to deal with this situation. No guidelines were in place at this inspection so this requirement would be reinstated. There were no guidelines either for the service user who has recently been admitted to the home. He could also be physically aggressive. This potentially leaves service users and staff at risk. The registered provider must take urgent action to resolve this on-going issue. Failure could results to serious repercussions to the health and welfare of service users. Grange Cottage Residential Home DS0000061844.V291713.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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally hygienic, clean, homely and comfortable however fire safety issue still need to be addressed as this potentially places service users and staff at risk. EVIDENCE: The home is suitable for its stated purpose. Furnishings and fittings were of good quality and the home was decorated to a reasonable standard. The garden is well maintained. “Door guard” catches have been fitted to some of the bedroom doors in line with requirement made at the last inspection. These ensure that the doors shut automatically in the event of a fire. However the home is not complying with fire regulations and there are also some health and safety issues (see standard 42). Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 18 The bedrooms were checked. They were decorated to a good standard. The rooms contained a variety of personal furniture and fittings that reflected the individual’s personality. The home is clean, hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Grange Cottage Residential Home DS0000061844.V291713.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): 27,29 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Generally staff are recruited appropriately to meet the health and social needs of the service users. However staff training needs to be addressed as this could have an impact on the standards of care being provided. EVIDENCE: Copies of the off duty rotas were seen. It was evident that on a number of occasions there was a shortfall in the number of staff on duty. The registered person was unable to comment and did not know if there were 2 or 3 staff on duties on certain days. The registered person must ensure that staffing numbers and skill mix of staff are appropriate to the assessed needs of the service users, the size, layout and purpose of the home, at all times. Failure to comply with the aforementioned requirement represent serious breaches of the Regulations and urgent action must be taken by the registered person to address these to avoid the Commission taking further action to enforce compliance. It was previously required that the manager must ensure that staff files must contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001.At the time of this inspection recruitment procedures seemed appropriate. Three staff files were examined at random and found to contain all the information required by the Care Homes Regulations 2001 Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 20 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. From the staff training records, it was noted that they were not always up to date and there are gaps in mandatory training. It was very difficult to ascertain if the staff were up to date with their training. The registered person must ensure that there is a staff training and development programme which meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. The registered manager must also ensure that a training needs assessment is carried out for the staff team as a whole, and an impact assessment of all staff development is undertaken to identify the benefits for service users and to inform future planning. Grange Cottage Residential Home DS0000061844.V291713.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): 31,33,36,37 and 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally managed well however the health, safety and welfare of service users and staff are not being promoted/protected and this potentially places them at risk. One-to-one supervision sessions are still not being held with staff on a regular basis, this could affect the staff’s ability to consistently meet the service users’ needs. EVIDENCE: Throughout the course of the inspection the manager demonstrated a good competent management skills. She has experience of working with this client group and displayed an insight into the relevant issues. She still has to achieve NVQ4 in management and care. She does not have a job description however Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 22 she stated that one is being drafted at present. This will be checked at the next inspection. The manager must also apply to the Commission to become the registered manager for the home. It was previously required that the manager must ensure that quality assurance surveys are extended from service users, relatives and friends to include visiting professionals and any other stakeholders. These are now in place. However the home still does not have an annual development plan based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service users. This remains outstanding and the requirement will be repeated. It was previously required that the registered provider must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. From staff supervision records it seems that not all staff are having at least six sessions per year and therefore this requirement will be repeated. It was previously required that the home must have a policies and procedures checklist. This should list all of the home’s policies and procedures, indicating when each policy was last reviewed. A copy should be included in each staff file, and should evidence that staff have read and understood each policy developed and reviewed.This is now in place. A number of health and safety issues arose during this inspection and they are as follows: The laundry room door was wedged open. The registered provider must ensure that doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. The fire exit at the rear of the property was not clear. There was an old bed, which was blocking the exit. The registered provider removed it on the same day of the inspection. The registered provider is required to ensure that all fire exits are kept clear at all times to ensure service users, visitors and staff safety. It was also noted that the side gate had a key operated pad lock. This is the only access to the front of the property from the back garden and is also use as a fire exit. The London Fire and Emergency Planning Authority was contacted on the day of inspection regarding this issue. They visited the home on the following day and have advised the provider accordingly. The registered person is required to ensure so far as is reasonably practicable the health, safety and welfare of service users and staff are promoted and protected at all times. Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 23 Certificates relating to health and safety were up to date servicing certificates. These included electrical wiring and installation, gas safety, fire safety and hoist maintenance. Grange Cottage Residential Home DS0000061844.V291713.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 X 1 Grange Cottage Residential Home DS0000061844.V291713.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 and 5 Requirement The home’s statement of purpose and service user’s guide both need to contain up to date information about the number, relevant qualifications and experience of all the homes staff team, including the managers, and include all details as per regulation 4 and 5. Previous timescale for action of 30/11/05 not met. The service user’s guide and the statement of purpose should be kept under review by the registered person and revised should any changes to the service occur. The registered person must ensure that service user’s plans are reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. Previous timescale for action of 30/11/05 not met. DS0000061844.V291713.R01.S.doc Timescale for action 31/07/06 2 OP1 4 and 5 31/07/06 3 OP7 15(2)(b) 31/07/06 Grange Cottage Residential Home Version 5.1 Page 26 4 OP7 15 The registered person must ensure that all service users have a care plan in place that sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. The registered person must ensure that service users care plans are drawn up after consultation with the service user, family, friends and an advocate where appropriate. The registered person must ensure that service users’ risk assessments are kept up to date and reviewed on regular basis and give details to what action is required to minimise identified risks and hazards. 31/07/06 5 OP7 15(1) 31/07/06 6 OP7 15(1) 31/07/06 7 OP18 12(1)(a) The procedure for responding to 02/05/06 suspicion or evidence of abuse or neglect must be amended to state that any abuse will be investigated by Care Management Team and not by the person in charge. The manager must make suitable arrangements by training all staff to prevent service user’s being harmed or suffering abuse or being placed at risk of harm and/or abuse. The manager must ensure that written guidelines are in place on how to deal with service users who can be physically aggressive.This must be discussed with the service users and their relatives. Previous timescale for action of DS0000061844.V291713.R01.S.doc 8 OP18 13(6) 31/07/06 9 OP18 13(7)(8) 02/05/06 Grange Cottage Residential Home Version 5.1 Page 27 30/11/05 not met. 10 OP27 18 (1)(a) The registered person must 02/05/06 ensure that staffing numbers and skill mix of staff are appropriate to the assessed needs of the service users, the size, layout and purpose of the home, at all times. The registered person must ensure that there is a staff training and development programme which meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. The registered manager must ensure that a training needs assessment is carried out for the staff team as a whole, and an impact assessment of all staff development is undertaken to identify the benefits for service users and to inform future planning. The manager must obtain an NVQ level 4 in management and care. The manager must apply to the Commission to become the registered manager for the home. The Registered Manager must ensure that an annual QA Development Plan is produced. This should include feedback from the surveys and assess the extent to which the home’s aims and objectives are being met. Previous timescale for action of 30/11/05 not met. DS0000061844.V291713.R01.S.doc 11 OP30 12(1)(a) (b) 31/07/06 12 OP30 18(1)(c) 31/07/06 13 OP31 9(1)(2) 31/12/06 14 OP31 9(1)(2) 31/07/06 15 OP33 24(2) 31/07/06 Grange Cottage Residential Home Version 5.1 Page 28 16 OP36 18(2) The Manager must ensure that 31/07/06 formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. Previous timescale for action of 30/11/05 not met. The registered provider must ensure that doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. The registered provider is required to ensure that all fire exits are kept clear at all times to ensure service users, visitors and staff safety. The registered person is required to ensure so far as is reasonably practicable the health, safety and welfare of service users and staff are promoted and protected at all times. 02/05/06 17 OP38 12(1)(a) 13(4) 18 OP38 12(1)(a) 13(4) 02/05/06 19 OP38 12(1)(a) 13(4) 02/05/06 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 Refer to Standard OP1 Good Practice Recommendations It is recommended that the service user’s guide is made available in a language and/or format suitable for intended service users. It is recommended that service users’ care plans are made DS0000061844.V291713.R01.S.doc Version 5.1 Page 29 2 OP7 Grange Cottage Residential Home available in a language and format that the service user can understand and is held by the service user unless there are clear and recorded reasons not to do so. 3 OP12 It is recommended that the activities timetable is circulated to all service users in formats suited to their capacities. It is recommended that the home’s complaints procedure is made available an appropriate language/format and is given and/or explained to each service user. 4 OP16 Grange Cottage Residential Home DS0000061844.V291713.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Grange Cottage Residential Home DS0000061844.V291713.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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