Inspection on 25/06/07 for Grangemoor House Nursing Home

This inspection was carried out on 25th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grangemoor House Nursing Home 09/01/07

Grangemoor House Nursing Home 21/12/05

Grangemoor House Nursing Home 22/02/05

Grangemoor House Nursing Home 17/08/04

Grangemoor House Nursing Home 26/01/04

Grangemoor House Nursing Home 18/09/03

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

CARE HOME ADULTS 18-65 Grangemoor House Nursing Home 110 Cannock Road Burntwood Walsall Staffordshire WS7 0BG Lead Inspector Jane Capron 25 th Unannounced Inspection June and 2nd July 2007 09:30 Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 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 Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grangemoor House Nursing Home Address 110 Cannock Road Burntwood Walsall Staffordshire WS7 0BG 01543 675711 n/a 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) Grangemoor Care Homes Andrew Mark Winter Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (10) Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2007 Brief Description of the Service: Grangemoor House is nursing home situated in Burntwood registered to accommodate 23 persons. The home in a residential area of Burntwood with good access to public transport and community facilities. The home is currently registered to admit residents suffering from a mental disorder, excluding learning disability or dementia (23) from the ages of 18 years and over. The home accommodates eight persons over the age of 65. A minor variation is required to ensure this is within the home registration. Accommodation is provided on two floors. On the ground floor, there is a lounge and smoking lounge, a dining room, kitchen, laundry facilities, five ground floor rooms, one of which is shared, an open shower and toilet facilities. The first floor has a range of shared and single rooms, a computer room/meeting room and suitable bathing and toilet facilities. A number of individuals are independent in relation to personal care and accessing community activities and support. The home needs to review its aims and objectives and give clear information within the Statement of Purpose as to the philosophy and practices of the home. At present, the home provides limited support for specific therapeutic activities to individuals to promote their mental health, independence and ongoing rehabilitation. The manager, Mr Andrew Winter informed the Commission on 16 January 2007 that the fee level for the home ranged from £480 to £487 per week. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days. The first day was completed by the Pharmacy Inspector who looked at how the service was managing people’s medication. The second day was completed by the lead inspector. This part of the inspection included looking at the information people were provided with before they moved to the service. We also looked at whether the service was meeting people’s health and personal care. We looked at what people could do at the service and if they were able to do lots of activities they liked and had the chance to develop their skills in doing every day things. We also looked at whether the staff had the right skills to work with people that lived there and how the service recruited its staff. We also looked at whether there were enough staff on duty. During the time we were there we looked round the service to see the standard of the accommodation. We also looked at the plans the service had to improve the service it provided. Before we went to the service we did a survey of relatives and people that lived there. We also talked to a social care professional that had contact with the service. The service also provided us with an Annual Quality Assurance Assessment, a document that the service completes to tell us what they do and their plans for the future. What the service does well: People we spoke to said they liked living at the service. Comments we received included: ‘I have been here 18 years and feel happy and settled’. One relative stated; ‘I have complete peace of mind knowing (my relative) is well looked after.’ The service assessed people to see if they could meet their needs. People were able to visit the service before they moved into the service to see if the wanted to live there. The staff we saw had a positive attitude and appeared to relate well with people that lived there. Comments about staff included: Staff will always have a chat’ and ‘the carers are very helpful’. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 6 We found that the service was meeting the health and personal care needs of people that lived there. The service took account of people with needs relating to old age. There was evidence of people receiving primary health care including dental and eye tests. People that needed it were receiving support from psychiatric health services. People that lived at the service were able to voice their views about the service. There were weekly meetings and questionnaires seeking people’s views. What has improved since the last inspection? What they could do better: Whilst the service had made progress there continued to be areas that needed to be addressed. We found that the Statement of Purpose and service user guide needed to include additional information and there was not a version that was easy to read. Whilst the service had started the process of revising and developing the plans of care these had not been completed. The plans needed to be further individualised and to include rehabilitation, promoting independence and the support people needed to look after their money. The service had started to develop behaviour management plans. We saw that the service had started to develop more opportunities for people to take part in activities in and out of the service but this could be further developed. We also felt that people could take part in more activities related to the running of the service. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 7 The service had started to increase its staffing so that it could people with the service as outlined in the Statement of Purpose. This process needs to be continued. The service had some care staff that had completed an NVQ qualification but the service would benefit from having more staff qualified. We found that the service should have more robust arrangements for safeguarding people’s finances to make sure there were no mistakes in the accounts and people were not paying tax on their savings unnecessarily. The service had started to talk to people about having locks on doors and locks were being put on bedroom doors. The service needs to make sure that everyone that wants to be able to lock their bedroom had a lock fitted. The service’s way of employing staff was not always safeguarding people because not all the checks had been done before some staff had started work. 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. The summary of this inspection report can be made available in other formats on request. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2,3 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service is moving towards providing the service as outlined in its documentation, however the information is not in an easy accessible format and does not cover all the areas required. The admission process ensures that an assessment is completed and that people have the opportunity to visit the service. EVIDENCE: Since the last inspection the service has reviewed its Statement Of Purpose/ service user guide. The Statement of Purpose covered most of the areas required under the Act although did not contain information about staffing provided, the fire precautions and emergency procedures, number and size of rooms and did not show how the service was making arrangements for respecting the privacy and dignity of the people that lived there. The service was starting to put in place programmes/ practices to demonstrate that it was promoting independence, normalisation and on-going rehabilitation of the individual’ as outlined as its stated aims in the Statement of Purpose. The information provided by the service was not in an easy read format that would accessible to most people. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 10 Case tracking showed that all prospective people were assessed by both the service and the placing authority. The assessment covered all the required areas. Discussions with several people that lived at the service showed that they had the opportunity to visit before they agreed to move into the service. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service has care plans are in place for all service users and has started the process of revising these to ensure that they are fully individualised and the person is fully involved in their development. People are involved in some aspects of running the service but there is scope for this to be further developed. EVIDENCE: We looked at a sample of care plans. These were not in a person centred format. The service was in the process of revising and up dating all the plans. The service was beginning to demonstrate that the people were being involved in planning and agreeing their plans. The plans we saw identified the health and personal care needs of people. We did notice that the service had common Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 12 care plans relating to activities of daily living and these needed to be individualised and further developed to reflect the specific needs of each person. We also saw felt that the service could further develop the information relating each person’s preferences. Since we visited last time the service had started to develop behavioural plans. The service had started to identify triggers to behaviour and plans were beginning to be put in place showing staff how to respond. These included proactive plans including diversion and distraction techniques. The service was restricting money, cigarettes and alcohol for some people but there was evidence that these had been agreed with the people and appropriate plans were in place. Since we visited last the service has started to plan and implement programmes to support people to take part in more independent living skills to enable support people to increase their level of independence. This still needs further development if it is to provide the service as outlined in its Statement of Purpose. People at the home said that they felt that the service consulted them. There was a weekly meeting where they talked about life in the service. There was scope for people to be more involved in aspects of running the service. The service was looking after some people’s money and the service needed to ensure that it had plans in place to show the level of support people needed to manage their money. People reported that they had choices over their daily life. One person said ‘ I can go out more or less when I want’. People were able to access their bedrooms and the communal rooms when they wanted. There were choices over meals and people reported that they were consulted over what was on the menus. People had the choice whether to take part in activities. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,7 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People were provided with the opportunity to take part in activities but did need to provide more opportunities for people to take part in independent living tasks both in the service and in the community. The service provided meals that were liked by the people that lived there and was based on their preferences. EVIDENCE: People that lived at the service had the opportunity to take part in a number of activities within the service. These included an art class, relaxation and keep Fit sessions every week. There was evidence of people’s artwork on walls at the service and one person told us that they enjoyed the art sessions. Some people attended a sheltered workshop receiving therapeutic earnings. Some people were able to go out of the service independently going shopping and for walks. People had the opportunity to go to church and one person we spoke to confirmed that they went every week. A staff member took them and a Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 14 member of the church brought them back to the service. One person told us that she liked reading and that a staff member brought her books from the library. The service took account of the differing needs of people due to their age or abilities. The service reported that they were investigating opportunities for people to attend colleges, a local day services and to obtain passes to attend a local leisure centre to take part in a range of physical activities. The service provided people with the change to go on external trips, which people seemed to enjoy. We required that further activities be provided on our last inspection and there continues to be scope for this to be developed. Some people took part in independent living activities such as clearing and laying tables and helping to clean their bedrooms. There was scope for people to be more involved in independent living activities and for their skills to be developed both in the service and in the community. One person told us that they did not go out much. People were not involved is food shopping or in food preparation. The manager told us that the staffing levels were in the process of being increased to enable to the service to support people to undertake a wider range of independent living activities. People confirmed that visitors could visit at any time and several people spent time out of the service with their family. People that lived at the service were encouraged to develop relationships with other people that live there and observation showed that people were sitting talking together and with staff. Routines were quite flexible. People told us that they chose when to get up and go to bed. They could choose where to spend their time. They could choose where to eat their meals. People said they liked the meals provided. Comments included: ‘Food good’ and ’Can have something else if don’t like it’. The service consulted people about the menus and arranged for meals to be ones that people liked. Snacks and drinks were reported to be available throughout the day. Some people had facilities in their bedroom to make drinks. The service was providing meals for people with special diets including people with diabetes and people that wanted a vegetarian diet. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service was meeting the personal care and health needs of the people that lived there. The service’s medication practices were now safeguarding the people that lived there. EVIDENCE: People’s support plans identified their health and personal care needs. Discussions and examination of a sample of plans confirmed that people were receiving the health care services. People were attending the GP when ill, they had dental and eye checks and those that required it had their nail care provided by a chiropodist. Support plans showed that the service was regularly reviewing people’s health care and there were assessments in place for tissue viability, continence and falls. The person on the last inspection that was using bedrails had been reassessed and the service had decided that rails were no longer necessary. People that required psychiatric services were being supported to attend for appointments. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 16 Discussions with people that lived at the service confirmed that their personal care needs were attended to and that where staff support was needed this was provided. People told us that they could have a bath or shower everyday and that they decided what to wear. We spoke to several staff and they were aware of each person’s personal care needs and how these were to be met. The pharmacist inspector visited as part of the key inspection. The medication management within the home had greatly improved. The home had moved over to using a Monitored Dosage System (MDS) to administer the residents’ medication from. This had brought more order to the medicines management systems within the home, with most of the medication being ordered on a set monthly cycle. Examination of the records found that the home was recording the receipt of all medication and if any medication was carried over from the previous monthly cycle the home was taking account of this in the new total. With the receipt of medication being so accurate it was possible to sample the medication and carry out a number of audits to discover whether the Medicines Administration Record (MAR) charts were accurate and the residents were receiving their medication as prescribed. It was disappointing to find that some of the audits did not balance and showed that some staff were signing the MAR charts when the administration of the medication had not taken place. This issue was identified with the manager and it appeared that he was aware of the situation and was taking steps to address it. Other improvements with the prescribing information were seen. The handwritten entries on the MAR charts were largely being written out correctly, the “as directed” labels had been amended so that the prescribers’ wishes were specifically shown and the home had developed written criterion for those medicines that had been prescribed on a “when required “ basis. The home had also developed a form to record and monitor the reasons for the administration of the when required medication. It appeared that all medication held within the home was now being stored securely, the home had acquired a lockable fridge (which was being used only to store medicines that required cold storage conditions) and the resident who was self medicating had relinquished her wishes and the staff were now in control of her medication. The home appeared to be struggling for space in their new trolley and advice was given on ways to solve this problem. Examination of the storage areas saw that all medicines were appropriately labelled with a dispensing label, there was no out of date stock, the internal and external medication was being stored separately and stock rotation was occurring. Examination of the fridge temperature records showed that the Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 17 home was still not measuring and recording the maximum and minimum temperatures on a daily basis. The Controlled Drugs cabinet had been properly secured to the wall and now met the Misuse of Drugs (Safe Custody) Requirements 1973. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People that lived at the service felt that their concerns were addressed. People were aware of the way to raise concerns and felt that the service would deal with any issues they raised. People felt safe at the service and staff were aware of protection issues however the service needed to ensure that there are no errors in financial records and people were not paying unnecessary taxes. EVIDENCE: The complaints procedure was displayed in the service and all people were provided with a copy. The service had amended its complaints procedure to show that people could contact the Commission with concerns. The service had received no recent complaints. People we spoke to confirmed that they knew how to raise concerns and they felt that the staff would sort them out. Comments included ‘ tell the manager and he’ll sort it out’ or ‘tell carer they would help me’. People that answered our survey said that the staff listened to them and would act on what they said. One relative said they did not know how to complain and it is recommended that they service makes sure that all relatives have a copy of the procedure. People told us that they felt safe at the service. One relative reported to us: ‘I have complete peace of mind knowing (my relative) is well looked after.’ Discussions with staff showed that they were aware of issues relating to protecting people and know who to respond if they had any concerns. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 19 The service had a number of people that could exhibit aggressive behaviour. The service had started to develop individual management plans to make sure that the staff were aware of how to respond to such incidents including the use of diversion and distraction techniques. On our last visit the service was restricting certain items of people that lived there. This was reported to be in their best interests however there was no evidence that these issues had been discussed and agreed with the people concerned. This has now been addressed and there was evidence to show that people were consenting to these arrangements. The service was looking after some people’s money. We did a sample check of the service’s arrangements safeguarding this money. Each person had their money kept separately and had individual accounts. We checked two peoples’ finances and in one case there was a slight error. The manager stated would be rectified immediately. We also found that people had bank accounts but they were paying tax on this. The service needs to address this. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25,26 ,27,28,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service provides people with private and communal accommodation that meets their needs and provides a warm and homely environment. EVIDENCE: We looked round the service seeing all the communal areas and a sample of bedrooms. The service provided the people that lived there were suitable accommodation. The communal areas were of a good standard. There were two lounges, one acting as the smoking room and smaller computer/ meeting room. There was a separate dining room. The service had a large kitchen. The service had a garden at the rear. The service had a number of double rooms and single rooms. The shared rooms had privacy curtains fitted and the one that was torn when we visited last had been repaired. We spoke to one person in a shared room and she said that she had been promised the next single room. The manager confirmed that this was the case. The bedrooms were saw had been well personalised with a Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 21 range of pictures, ornaments and belongings of the occupant. The bedrooms were not lockable but the service had started the process of talking with people about whether they wished to lock and to have locks fitted. One person told us that she was having a lock fitted. The service had sufficient bathrooms and toilets. The service had addressed the requirement made at the last inspection to have a thermostat fitted on the bath without one. The service was seen to be clean and tidy throughout. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The service must ensure that there are always sufficient staff on duty to provide people with the service as outlined in its Statement of Purpose. Staff have the necessary knowledge to work with the people that live at the service. The service did not have a recruitment process that safeguarded the people that lived there. EVIDENCE: The service’s staffing levels and staff’s knowledge and skills were looked at during the inspection. The service always had qualified nurse on duty and at least two care staff on duty throughout the day. There were times when there were three care staff on duty and the manager informed us that when they have recruited the staff there would always be at least three care staff on duty. This level of staffing will enable the service to undertake more of the rehabilitation and promoting of independence that it states it undertakes in its Statement of Purpose. At night the service has one nurse and one care staff member on duty. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 23 We talked to some of the staff on duty. They demonstrated that they were aware of the needs of the people that lived there being able to describe what care each one required and how these needs were to be met. We observed several staff supporting people and felt that they had positive and relaxed relationships with the people that lived there. People that lived their commented: ‘staff listen to me’, ‘staff are kind’ and ‘staff-very good, they always ask if they can come in my bedroom’. The service had altered how it stored its staff files ensuring that the senior staff on duty could access them if needed. We saw that the service was providing staff with induction training and all the required health and safety training. Staff had received training in mental health issues, health issues and adult safeguarding. The service informed us that five staff had completed NVQ level 2. We looked at a sample of staff records to see how the service was recruiting its staff. We found that the service was not always ensuring that suitable references were sought and one nurse who was working at the home, at times as the senior staff member did not have satisfactory POVA or police check. We also found that the service was not keeping proof of identity documents on file and that there was no check that prospective staff were medically fit to undertake the work. We made an immediate requirement that the person could not be the senior staff member on the premises and must work under supervision until satisfactory checks were received. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service’s manager has the necessary qualification and experience to lead the service. The service has a quality assurance system in place that takes account of the views of the people that live there. The Health and Safety procedures in the service were protecting the people that lived there. EVIDENCE: The registered manager has worked at the service since 1991. He Registered Mental health Nurse and has lengthy of working with people mental health needs. The manager informed us that he was now making that he had supernumery to undertake his management role rather having to do this as well as undertaking his nursing role. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 is a with sure than Page 25 Comments received from one relatives and people that lived there included: ‘Have complete confidence in manager.’ and ‘I rank the manager and clinical staff with the highest esteem’. The service had responded to the requirements made at the last inspection and had either completed or had started to complete the actions they needed to address. The issues over the recruitment of staff must be addressed to ensure the safety of the people that live there. The service had some quality assurance systems in place. Relatives and people that lived there completed questionnaires to gain their views of the service. Regular meetings were held with the people that lived there. The manager also undertook audits of the environment, infection control, health and Safety and care plans. He had introduced a procedure to complete regular drugs audits. The fire records were examined. The fire alarm and the emergency lighting were being tested and there were regular fire drills. Staff were receiving fire training including one by a fire specialist once a year. The home had completed a fire risk assessment and put in place an evacuation plan. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 X LIFESTYLES Standard No Score 11 2 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 3 X X 3 X Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 4 (1)(2) Requirement To review the Statement of Purpose/ Service user guide to ensure that it contains all the information needed by people who may consider living at the service. To ensure that individualised and comprehensive plans of care are in place that includes rehabilitation needs, plans to promote independence and support needed to manage finances so that all the information is available to meet the needs of the people that live at the service. Timescale for action 01/09/07 2. YA6 15 (1)12 (1)(a) 01/09/07 3. YA14 16 (2)(m)(n) 4. YA23 13(6) 5. YA33 18(1)(a) To consult service users 01/09/07 regarding suitable activities within the home and the community, and for these to be implemented (Timescale of 28/02/07 not met) Where the service is looking 13/08/07 after people’s money there must be a robust procedure in place so that people are protected. To ensure that there are 01/09/07 adequate staff on duty so that the people that live at the DS0000022328.V338313.R01.S.doc Version 5.2 Page 28 Grangemoor House Nursing Home 6. YA34 19 Schedule 2 service receive care as outlined in the Statement of Purpose The employee without a CRB must always work under the supervision of another staff member and must not be in charge of the service. This will safeguard the people that live at the service. Prior to people working at the service they must have the necessary pre employment checks. This will ensure that people are safeguarded. 03/07/07 7. YA34 19 Schedule 2 23/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA1 YA8 YA22 YA26 YA32 Good Practice Recommendations To provide the Service user guide in a format that is accessible to all people that live at the service. To provide more opportunities for people to participate in running the service giving people the chance to be involved and have more control and choice over their lives. To ensure that all relatives are aware of the service’s complaints procedure. To provide locks on bedroom doors for those that wish them so that people’s privacy is increased. That the number of qualified staff working at the service is increased in order that people receive care from well trained staff. Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Local Office Commission for Social Care Inspection 1st Floor 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Grangemoor House Nursing Home DS0000022328.V338313.R01.S.doc Version 5.2 Page 30 - 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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