Inspection on 07/11/06 for Grangewood

This inspection was carried out on 7th November 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Grangewood 01/02/06

Grangewood 14/10/05

Grangewood 05/10/04

Grangewood 08/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Beau Sejour

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

CARE HOME ADULTS 18-65 Grangewood 10/12 High Street Kelvedon Colchester Essex CO5 9AG Lead Inspector Ray Finney Key Unannounced Inspection 7th November 2006 10:00 Grangewood DS0000017835.V319775.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 Grangewood DS0000017835.V319775.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. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grangewood Address 10/12 High Street Kelvedon Colchester Essex CO5 9AG 01376 570208 01376 571739 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) SCOPE Mrs Marie Jones Care Home 19 Category(ies) of Learning disability (19), Learning disability over registration, with number 65 years of age (2), Physical disability (19), of places Physical disability over 65 years of age (2) Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability who may also have a physical disability (not to exceed 19 persons) Two persons, aged 65 years and over, who require care by reason of a learning disability who may also have a physical disability, whose names were made known to the Commission in March 2003 1st February 2006 2. Date of last inspection Brief Description of the Service: Grangewood provides a residential service for younger adults and older people with disabilities associated with cerebral palsy. The home was originally registered as two buildings with the original seventeenth century house having two floors accommodating some service users with offices on the first floor. However, since the intended redevelopment of the site the service users are no longer accommodated in the older premises and all now live within the purpose-built one storey building adjacent to the older house. The premises have adequate wheelchair access. The single storey accommodation provides single bedrooms, one with en-suite. The home is arranged into two smaller units, each with its own sitting and dining room spaces. Service users also benefit from a ground floor activity area. Outside the building are large, enclosed and well-maintained grounds. There are ample car parking facilities. The old building The Grange now provides a staff sleep-in room, guest flat, family room, staff and a service users training room. Information about the service may be obtained by contacting the manager. The home charges between £770.00 and £1,273.00 a week for the service they provide. Service users pay extra for personal items such as toiletries, clothes, hairdressing and admission fees to leisure and recreational activities of their choice; the cost for these is normal retail prices. This information was given to the Commission in November 2006. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to compile this report. The manager provided information in a Pre-inspection Questionnaire. Documentary evidence was examined, such as staff rotas, menus, service users’ care plans and staff files. Completed surveys were received from service users. Overall comments received from service users are positive: “This is the best home. I like this place”, “I like it here, it’s good” and “I usually get on well with all the staff. I like living at Grangewood”. A visit to the home took place on 7th November 2006; this included a tour of the premises, discussions with service users, members of staff and the manager and observations of interactions between service users and members of staff. On the day of the inspector’s visit the atmosphere in the home was lively and welcoming and the inspector was given every assistance from the registered manager, Marie Jones. What the service does well: What has improved since the last inspection? Since the last inspection there have been a number of improvements to the environment and the décor in the home. There is an ongoing Premises Improvement Plan that has included the redecoration of some bedrooms and Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 6 one of the kitchens and replacement flooring in some bedrooms and communal areas. A programme of refurbishment of bathrooms and toilets is continuing. Service users’ files have been reorganised and the manager continues to develop and improve service user records. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 7 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 Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 8 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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have the information they need to make an informed choice about where to live. The home ensures service users are admitted on the basis of a full assessment. The service ensures service users have a contract with the home. EVIDENCE: On the day of the inspection the Service Users’ Guide and the Statement of Purpose were examined. As stated in the Pre-inspection Questionnaire, the Service Users’ Guide was updated in February 2006. The home also has a ‘Charter of Rights’ that has been developed with service users. There is a process in place for assessing service users’ needs before admission. A discussion with the manager demonstrated an excellent awareness of the importance of a good pre-admission assessment. Three service users’ care plans, including that of the most recently admitted service user, were examined and all contain comprehensive pre-admission assessments. There is good evidence that individual needs being assessed are linked to care plans (see evidence for National Minimum Standard 6). Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 9 Records examined show that there are contracts in place that have been signed by the home and by the service users or their representatives. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 10 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs and goals are reflected in their Individual Plans. Service users are supported to make decisions about their lives and are supported to take risks within the limitations of their capacity to understand. The home ensures service users are supported to participate in all aspects of life in the home. EVIDENCE: A sample of three service users’ care plans was examined, including that of the most recently admitted service user. All were found to contain wide-ranging and detailed information. Records are well organised and on the day of the inspection visit the manager was in the process of updating records. Care plans examined relate to the assessments of need. Care plans cover areas such as daily routines, communication, finance, relationships to maintain, religious/cultural needs and mobility. There is evidence in the records that annual reviews take place and care plans are reviewed regularly. The manager Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 11 and other staff spoken with demonstrate a good of awareness of service users’ needs. The standard of care planning has been shown to be consistently good when examined at previous inspections and the standard continues to be good. Records examined show that personal care needs are well documented and contain sufficient detail to ensure service users receive care in the way they choose. Observations of interactions between members of staff and service users on the day of the inspection visit show that the home supports service users to make choices about their lives. The home’s ‘Charter of Rights’, which was reviewed in February 2006, was examined. It was developed in conjunction with service users and clearly documents the rights of service users such as the right to have a key to their bedroom door, to be able to make a complaint, to have a telephone in their room, to have their privacy and confidentiality respected at all times, to be involved in menu planning, to be involved in staff recruitment and to make choices and decisions about their lives. The manager discussed the Service User Empowerment Group that is being piloted by SCOPE. The group includes service users from the home together with service users from another SCOPE home in the area. The three-month pilot scheme is designed to empower service users by helping them develop skills around decision-making and gain knowledge about their rights. Service users spoken with are enjoying the meetings and the work that they are doing. The home holds regular monthly meetings with service users; politics and voting were discussed at the previous service user meeting. Observations on the day of the inspection visit show that service users are supported to participate fully in the running of the home. Service users’ records examined contain comprehensive risk assessments identifying concerns, existing precautions and additional precautions required. The manager and staff spoken with demonstrate a good awareness of the process of assessing and minimising risk. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to take part in a range of age, peer and culturally related activities and are part of the local community. Service users are supported to maintain appropriate relationships. The home ensures service users’ rights are protected and responsibilities recognised in their daily lives. Service users are offered a varied and healthy diet that they enjoy. EVIDENCE: The activities co-ordinator explained that the home has ‘gap year students’ who make a great contribution to the activities programme. The next intake of gap-year students is scheduled for January. At the time of the inspection visit the home had two overseas volunteers. The activities co-ordinator displayed an enthusiastic approach to the role. Activities taking place were observed to be enjoyed by those taking part. Service users’ records examined have good information about activities including the use of pictures. The variety of inGrangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 13 house activities include dance classes twice weekly, art and craft classes twice weekly, a record club, computer classes, drama, bible studies and pottery. Community recreational and educational activities that service users access include Castlegate over 40 Club, Sports Spectacular, Soled Out Dance, Aromatherapy, Cinema, Crazy Art, shopping trips and out to lunch. One service user has been supported with a campaign to get a zebra crossing sited near the home so that service users can access the local post office more safely. The service user has written letters to the local council and highways department and has got together a petition containing about 300 signatures. So far there has been some success in that the proposed crossing further up the high street has been put on hold. The service user showed enthusiasm for sharing the information about this achievement with the inspector. Discussion with manager confirms that good family links maintained. Care plans examined include details of relationships that are important to the service user. Service users spoken with on the day of the inspection visit confirm they are helped to maintain family relationships. The inspector observed that staff working with service users display very positive attitudes. General observations of interactions between staff and service users show service users are treated with respect, their opinions are sought, service users are encouraged to make choices and communication is good. The home’s Charter of Rights states that service users have the right to be involved in menu planning. Discussions with members of staff show that choices and decisions about meals are made on a daily basis. Service users spoken with say that they enjoy the food and the lunchtime meal on the day of the inspection visit was seen to be relaxed and enjoyable. A tour of the premises shows that the kitchens are domestic in nature, clean and food is stored appropriately. A variety of nutritious food is available including fresh fruit and vegetables. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 14 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 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures service users receive personal support in the way they require and their physical and emotional needs are met. Service users are protected by the home’s policies and procedures for dealing with medicines. Service users can expect their wishes to be met around aging, illness and death. EVIDENCE: Records examined show evidence of the way service users prefer to have personal care carried out (see evidence for standard 6). The comprehensive information in the care plans ensures that staff have the guidelines they need to provide care in the way the service users wish. The home operates a key worker system and staff spoken with are able to demonstrate an awareness of service users’ preferences. Records examined show that the home provides a good standard of care in relation to service users healthcare needs. There are comprehensive health assessments in place including physiotherapy, manual handling needs and Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 15 assessments relating to specific medical conditions such as epilepsy and deafness. During a tour of the premises evidence was seen that the home provides appropriate aids and adaptations such as overhead tracking, electric hoists, assisted baths, electric wheelchairs and standing frames to maximise independence. All service users are registered with local General Practitioners and are supported to access healthcare facilities as and when required. Records examined contain evidence of medical appointments including chiropodist, dentist, optician, physiotherapist, and sensory nurse. Care plans contain weight charts. The home operates a monitored dose system for the administration of medication. The storage of medication was examined and all was found to be clearly labelled and stored appropriately. A separate fridge is available for storage of medications requiring controlled temperature. Medicine Administration Record (MAR) sheets were examined. MAR sheets are correctly completed and contain pictures of service users to minimise the risk of giving the wrong medication. Care plans examined contain relevant information about prescribed medication. Staff files examined contain evidence of staff training around the administration of medication. The inspector observed a senior carer administering lunchtime medication whilst being shadowed by another member of staff and the process was carried out carefully and appropriately. There are no controlled drugs in use in the home at the current time and no service users are self-medicating. The procedure around the storage and administration of medication is robust. The home has an appropriate policy in place around death and dying. Service users’ records examined contain details of what arrangements are to be made in the event of terminal illness or death. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 16 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident their views are listened to and acted on. Arrangements are in place to help protect service users from abuse, neglect and self-harm. EVIDENCE: The home has a robust complaints policy and procedure in place, which contains timescales for responding to complaints and information about how to contact the Commission for Social Care Inspection. On the day of the inspection visit the process was discussed with the manager, who shows a good awareness of her responsibilities around dealing with concerns and complaints. The documentation around the recording of complaints was examined; concerns and complaints are recorded appropriately and fully; the outcome of the complaint is clearly documented. Records examined show that the home has policies in place for the Protection of Vulnerable Adults (POVA). There is a whistle blowing policy in place so that staff may be assured that they will be protected if they feel the need to raise concerns about practices. As part of the recruitment process, the home carries out Criminal Records Bureau (CRB) enhanced disclosure checks to ensure the protection of service users. Training records examined indicate that staff have had POVA training; the home uses the ‘Safeguarding Vulnerable Adults’ DVD training pack. The manager is able to demonstrate a good awareness of Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 17 responsibilities around protecting vulnerable adults and a recent protection issue in the home has been dealt with sensitively and appropriately. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 18 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, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall service users live in a homely, comfortable and safe environment and they can expect the home to be clean and hygienic. The home ensures service users have the specialist equipment they need. EVIDENCE: The inspector was accompanied on a tour of the premises by the manager and two service users. Although the building is older and requires updating in some areas, there is an ongoing programme of refurbishment called the Premises Improvement Plan (PIP). During the inspection extensive work was being carried out on one of the bathrooms, one shower/toilet and another toilet area. Another bathroom has been decorated by service users with bright murals on the walls and service users spoken with are very proud of their achievement. Information provided in the pre-inspection questionnaire shows that a total of five bedrooms have been redecorated with a further three planned by the end of the year and new flooring has been laid in three Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 19 bedrooms. flooring. Also, one dining area has been decorated and has had new Service users’ bedrooms are decorated to reflect their individual tastes; the inspector spoke to one service user about the choice of a lovely bright, vibrant colour scheme in their room. Bedrooms clearly reflect the individual personality of each service user and contain plenty of evidence of personal possessions. The kitchen and living areas are homely and comfortable. Furnishings throughout the home are domestic in nature and of good quality. A tour of the premises showed evidence throughout the home of suitable aids and adaptations, including overhead tracking and hoists, to ensure service users are able to be as independent as possible. Documentation examined shows that hoists and adaptations are well maintained. One service user has specialist equipment to help turn on lights and close curtains. The management team have had training and are delivering this to staff using ‘Safer Food Better Business’ pack from the Food Standards Agency. A tour of the premises showed a good standard of cleanliness throughout the home and it is free from any offensive odours. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 20 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): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff who receive appropriate training. Service users are protected by the home’s recruitment policy and procedures. The home ensures service users benefit from well supported and supervised staff. EVIDENCE: Discussions with the manager indicate that out of a total of 23 care staff, 8 have completed a National Vocational Qualification (NVQ) at level 3, 5 have completed NVQ level 2 and a further 3 are working towards NVQ level 3. One senior carer is doing an NVQ ‘A1’ assessor course. Discussions with the manager and members of staff indicate that there is good support for staff training, particularly in NVQ. The home has an NVQ forum to support staff in gaining their awards. The number of staff with NVQ at level 2 or above are in excess of 60 , which exceeds the National Minimum Standard of a recommended 50 of carers. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 21 The home’s Charter of rights states that service users have the right to be involved in recruitment. Discussions with the manager indicate that some service users choose to be actively involved in the interviewing process. The home has a robust recruitment process in place to ensure the protection of service users. The manager is able to demonstrate a good awareness of the requirements of the standards relating to the recruitment of staff. Staff files examined contain all the required documentation including two written references, appropriate evidence of identification (ID), photographs and enhanced Criminal Record Bureau (CRB) checks. Staff files are very well organised. Records examined show that the home has a good training and development system. Staff files contain evidence of a comprehensive in-house induction using the new SCOPE induction units; three members of staff have completed Learning Disabilities Awards Framework (LDAF) training. A full range of training is documented in the Pre Inspection Questionnaire and on the home’s Training & Development Plan; training available includes Adult Protection/Whistle blowing/ Protection of Vulnerable Adults (POVA), Health & Safety, Fire Drill Procedure/Fire Drills/Fire Safety, Vehicle Safety, Manual Handling, Food Hygiene, Boots Monitored Dose System (MDS), First Aid, Continence Management, Recruitment & Selection, Investigations and Disciplinary, Managing High Performance Teams, COSHH, Infection Control, Work flow systems, Safer Food Better Business, Disability Equality and Empowerment, Ill Health and Sickness Procedures, Performance Management and Finance training. Future training planned includes updates of statutory training where required, also the Role of the Key worker, Behaviour/Conflict Management, Continence/bowel management and Complaints. Staff records examined contain evidence of regular supervision and staff spoken with feel well supported. Discussion with the manager in relation to POVA indicated that she puts a high priority on ensuring staff receive sound support. Staff have Personal Development files with details of training, annual appraisal and supervisions that meet the requirements of the National Minimum Standard. Discussion with the manager and information provided in the pre-inspection questionnaire indicates that the home has a stable staff team with a low turnover of staff. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 22 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and had policies and procedures in place to safeguard the rights of the service users. The home ensures that service users views are taken into account through the Quality Assurance process. The home ensures the health, safety and welfare of service users are promoted and protected. EVIDENCE: The registered manager has a number of years management experience and holds the Registered Manager’s Award qualification. Discussions with manager indicate she has a good awareness of the procedures needed to run the home. Grangewood has a range of well-constructed policies that the manager implements to ensure the home is run in the interests of service users. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 23 Discussion with the manager shows evidence of ongoing training and peer support from managers of other SCOPE homes, which ensures that ideas and good practices are shared. An open atmosphere and good interactions were observed between the manager and members of staff. The home has a Quality Assurance system in place that is based on seeking the views of service users. Surveys have been updated and distributed to stakeholders and service users. The results of the returned surveys have been collated into a comprehensive report. An action plan has been devised for Grangewood in response to information received from service users and stakeholders. The action plan identifies areas for development, including environmental improvements, allocation of keyworkers, accessing more external, recreational and social activities and training for service users regarding complaints procedure. The Quality Assurance system is robust and well-developed. Service user meetings and empowerment training ensure service users are able to make their views known. On the day of the inspection visit, the inspector observed how management and staff actively listen to service users. Records examined show that the home has comprehensive risk assessments in place relating to Health & Safety; risk assessments cover Control of Substances Hazardous to Health (COSHH), bathing, bed safety, moving & handling, medication, wheelchairs, electrical installations and water systems. Risk assessments contain evidence that they were reviewed in June 2006. Records relating to Health & Safety are well organised and all were found to be in order. The home has appropriate policies and procedures in place around infection control, COSHH, fire safety, food safety, first aid and Health & Safety. Information provided in the Pre-inspection Questionnaire and records examined indicate that appropriate Health & Safety checks are carried out; fire equipment was checked 05/09/06, fire alarms are checked weekly and the most recent fire drill was carried out 02/10/06, the water system was checked and a new boiler was installed 02/10/06, water temperature checks are carried out weekly, hoists and specialist equipment all have evidence of recent servicing. Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 3 3 X 3 X X 3 X Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Grangewood DS0000017835.V319775.R01.S.doc Version 5.2 Page 27 - 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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