Please wait

Inspection on 07/12/04 for Grangewood Lodge

Also see our care home review for Grangewood Lodge for more information

Care Home For Older PeopleGrangewood LodgeNetherseal Swadlincote Derbyshire DE12 8BHAnnounced Inspection7th December 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Grangewood Lodge Address Netherseal, Swadlincote, Derbyshire, DE12 8BH Email address Name of registered provider(s)/company (if applicable) Mr John Frederick Fisher Name of registered manager (if applicable) Ms Amanda Fay Hatfield Type of registration Care Home No. of places registered (if applicable) 30 Tel No: (01827) 373577 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (30) Registration number C020000151 Date first registered 2nd July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 17th August 2004 YES NO 6/7/04 If Yes refer to Part CGrangewood LodgePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 37th December 2004 09:30 am Claire WilliamsID Code131281Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNA Fay HatfieldGrangewood LodgePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementGrangewood LodgePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Grangewood Lodge. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Grangewood LodgePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Grangewood Lodge is a Care Home registered to provide personal care and accommodation for up to 30 people in the category of older persons. In August 2004 the Registered Person increased the occupancy of the service users accommodated at Grangewood from 27 to 30. Grangewood Lodge is located near to the village of Netherseal. Grangewood Lodge has extensive grounds, a patio area, and a care park Grangewood Lodge has 25? single rooms, and 2 double rooms, of these 16?single rooms and 2 shared room have en-suite facilities. A variety of lounge and dinning space is provided. There are sufficient bathing facilities to meet the needs of the service user group. Service users accommodation is located on the ground and first floor of the building, and there is a stair lift for access. The Registered Person is currently investing and upgrading some of the bedrooms. Plans have been submitted to change the layout and purpose of two bedrooms.Grangewood LodgePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This report has been produced following a routine Announced inspection visit. The Registered Manager has addressed majority of the previous requirements made in the unannounced inspection report, which was carried out in June 2004. Both the Registered Manager and the staff team have worked really hard in preparation for this inspection, and in ensuring that the service provision provided is of a good standard. Service users commented positively about the care provided and about the staff team and the Registered Manager. The inspector used case tracking methodology which involves the examination of records/documents, discussion with (the individual service users, staff and where appropriate relatives) and evidence in relation to individual service users to determine how the National Minimum Standards work for them in practice. Three service users were case tracked during this inspection visit. Choice of Home: (Standards 1-6) 5 out of 5 standards were assessed. 5 out of 5 Standards assessed were met The Statement of Purpose and Service User Guide had been produced and include all the areas as required by the National Minimum Standards and Care Home Regulations. The Registered Manager visits all prospective service users and completes a pre-admission assessment. Statement of terms and conditions/contract were in place for the service users whose care was case tracked. Service users and relatives spoke highly of the standard of the care they received at Grangewood Lodge, and how caring and committed the staff team and the Registered Manager are. Health and Personal Care (Standards 7-11) 5 out of 5 standards were assessed. 4 out of 5 Standards assessed were met The Registered Manager has developed new care plans and these have been implemented for all service users. The care plans cover the areas identified in National Minimum Standards 3.3, and give a holistic overview of the service users needs. The care files case tracked was well organised, and easy to read. All three files contained all of the required information. There was evidence in all three care plans that they are reviewed on a regular basis, and that the plan was developed in consultation with the service users. Service users confirmed that they receive services from health professionals as required. A small number of issues around administration of medication were noted and are contained within the main body of the report. Service users confirmed that they receive support in personal care tasks in a manner that promotes their privacy and dignity.Daily Life and Social Activities (Standards 12-15): 4 out of 4 standards assessed. 4 out of 4 standards met Grangewood Lodge Page 6 Service users commented that routines were flexible within the home. Preferred routines of daily living and preferred activities were identified within care plans. Grangewood Lodge offers a range of activities on a daily basis. Service users commented that they are able to see visitors either in communal areas or in the privacy of their own room. Visitors informed the inspector that they are always made to feel welcome in the home. Service users and relatives commented positively about the quality of the food provided. Complaints and Protection (Standards 16-18): 3 out of 3 standards assessed. 3 out of 3 standards met The complaints procedure was on display, and contained within the Statement of Purpose and Service User Guide. Service users whose care was case tracked and those who spoke with the inspector were aware of how raise their concerns and were confident that any issues would be dealt with appropriately. The information provided from the service user and relative comment cards indicated that the majority of service users and relatives were aware of how to raise their concerns. Procedures to safeguard service users from abuse were in place. Some staff have received relevant training through their NVQ training, and internal training was planned. Staff who spoke with the inspector indicated that they had no concerns or suspicions of abusive situations taking place in the home. Environment (Standards 19-26): 8 out of 8 standards were assessed. 8 out of 8 Standards assessed were met Grangewood Lodge was well maintained and decorated throughout. Both service users and relatives spoke positively about the environment and the standard of cleanliness. Service users have had the opportunity to personalise their bedrooms. Service users have access to a range of toilet and bathing facilities. The domestic upkeep of the home is to a good standard. Staffing (Standards 27-30): 4 out of 4 standards assessed. 2 out of 4 standards met The planned staffing levels provided at Grangewood Lodge were in accordance with the Residential Staffing Forum for the occupancy and dependency levels. 35 of the staff team have achieved NVQ Level 2 or equivalent, 8 staff members are currently undertaking an NVQ. Robust systems were in place for the recruitment and selection of staff, and the Registered Manager was aware of the recent changes relating to the Protection of Vulnerable Adults (POVA) list. Induction training is provided. The Registered Manager must check that the training covers the National Training Organisation specifications. Management and Administration (Standards 31-38): 8 out of 8 standards assessed. 8 out 8 standards met The Registered manager has completed the NVQ Level 4. Service users, staff members and relatives commented that the Registered Manager was approachable, supportive and friendly. The Registered Manager works alongside staff in order to maintain communication and a professional relationship with both the staff and the service users. All staff confirmed that they receive regular supervision. All maintenance records checked were found to be satisfactory.Grangewood LodgePage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Grangewood LodgePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 13 (2) 17 (1) (a) OP9 Schedule 3 13 (2) 17 (1) (a) OP9 Schedule 3 13 (2) 17 (1) (a) OP9 Schedule 3 All Handwritten medication instructions must 31/2/05 be checked and countersigned by two people. When using codes on the MAR chart the reason for the use of the code must be recorded if it is different form the codes already identified. The Registered Manager must develop an assessment of medication competence The Registered Manager must update the staff application form in order to request a full employment history and a written explanation of any gaps. The Registered Manager must ensure that the induction training meets the National Training Organisation workforce training targets.231/2/05331/3/054Schedule 2 OP2931/3/05518 (c) (i)OP3031/3/05Grangewood LodgePage 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The Registered Manager should include the contact details of the social services and health care authorities within the Service User Guide or Statement of Purpose. The Registered Manager should develop a falls risk assessment, which should be completed on all new admissions, and service users considered a high risk. The Registered Persons should devise a policy on Gender and personal care issues. The Registered Person should consider replacing the kitchen and stores flooring. Service users should have the provisions identified in National Minimum Standards 24.4 in their bedrooms or their preferences should be recorded in their care files.1OP12OP83 4OP10 OP195OP24* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Grangewood LodgePage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES NO YES YES YES YES NO NA YES YES YES NO YES YES YES YES NO YES YES YES 9 3 0 YES YES YES YES 15 8 7/12/04 9.0 9.5Grangewood LodgePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Grangewood LodgePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes 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 residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 300 To (£) 330Any charges for extrasYEStaxi, toiletries clothes If yes, please state what the extras are: 3 Key findings/Evidence Standard met? The Registered Manager has produced a Statement of Purpose and Service User Guide. The inspector examined these documents, which contained all the required information in accordance with the National Minimum Standards and the Care Homes Regulations 2001. The documents contain information, which will enable service users to make an informed choice about the possibility of moving into the home. The Service User Guide contained additional information in relation to the Service Users Charter and the aims and objectives of Grangewood Lodge. A copy of the inspection report and comments from both service users and relatives are available in the Service User Guide. These documents are available in large print.Grangewood LodgePage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Statements of terms and conditions/contracts were in place for the three service users whose care was case tracked. Those service users whose care is funded by the local authority were also issued with the statement of terms and conditions. All three-service users had signed this document in agreement. The terms and Conditions contained all of the information as prescribed by the National Minimum Standards and Care Home Regulations. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The inspector case tracked the care of three service users using case tracking methodology. There was a pre-admission assessment completed for all three service users. The assessment covered all the areas as prescribed by National Minimum Standard 3.3. The Registered Manager confirms in writing to all service users that having regard to the pre-admission assessment Grangewood Lodge is suitable for the purpose of meeting the service users needs in respect of their health and welfare Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 4 Key findings/Evidence Standard met? Comments from service users and relatives supported that the staff team were able to meet the needs of the service users. Many service users commented that `the best thing about the home was the care and that the staff team are really friendly. Staff who spoke with the inspector was able to clearly describe the care needs of the service users. The Registered manager and the staff team promote the independence of the service users, and encourage all service users to retain or develop self-managing skills. The needs and preferences of service users with hearing or visual impairments are supported through the availability of aids and adaptations. In order to fully support and meet the needs of the service users, the staff team have received awareness training in a variety of areas in addition to the mandatory training available, Relatives who spoke with the inspector stated that the staff team always welcome them when they visit the home and that the Registered manager always keep me informed. Relatives also commented that the care is second to none Based on these positive comments a score of 4 has been awarded on this occasion. Relatives and service users also informed the inspector that Grangewood Lodge has a very good repetition in the community and is some service users moved into the home base on the positive comments they heard about the home from visiting family members.Grangewood LodgePage 14 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Grangewood Lodge offers all prospective service users an opportunity to visit the home, before they make a decision about admission on a longer-term basis. This includes a tour around the building, introductions to the service users and staff team, and a meal. The trial visits are service user led. Some Service users informed the inspector that they came to the home for a period of respite which enabled them to make an informed decision about their longer term needs and the home they wanted to move into. Two service users told the inspector that they initially came into the home for respite and then decided not to return home, as they was happy and content to remain at the home. Relatives who spoke with the inspector confirmed the procedure for trial visits, and commented on the importance of being able to spend time in the home before making a decision. Grangewood Lodge offers 3 day care places which also enables service users to become familiar with the staff and service users and the routines at the home. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 0 Key findings/Evidence Standard met? Grangewood Lodge does not offer intermediate care. Therefore this standard is not applicableGrangewood LodgePage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 4 Key findings/Evidence Standard met? The inspector case tracked the care of three service users using case tracking methodology. The Registered Manager has developed new care plans, and the staff team have worked hard in order to implement the new care plans for all the service users in preparation for the inspection visit. The new Care plans were well set out and easy to read. They covered all the areas outlined in Standard 3.3. Care files contained a photography of the service user. The service user and their representative had signed their care plan in agreement with the contents. Each file contained moving and handling risk assessments, and general risk assessments, and these were reviewed regularly. Each file contained the service users personal profile and preferred routine and preferences on how they would like to be supported in personal care tasks. Inventories had been completed for personal items brought into the home. Grangewood Lodge operates a keyworker system and the designated Keyworker completes a monthly review of the service user needs. There was evidence in all three files that the care plans had been reviewed, in consultation with the service user who had signed the review form in agreement with the identified changes to the care plan. Key workers then complete a six monthly summary of the service users support needs, identified changes and significant life events etc. This information is collated and discussed with the service user in preparation for the six monthly review, which is a formal review of the individuals care, and support needs. Relatives who spoke with the inspector confirmed that they was invited to the reviews. Daily logs were completed for each service user; these were signed and dated by the staff team. There was daily recording for all three service users whose care was case tracked. The standard and the consistency of the recordings had improved since the previous inspection. A senior supervisor for key workers has been implemented into the staffing structure, and the role includes monitoring the care plans. The senior also audits the daily logs and signs them to evidence this. Due to standard of the assessments implemented and service users consultation in the development and the regular review of their plan, a score of 4 has been awarded on this occasion. Grangewood Lodge Page 16 Grangewood LodgePage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 0 03 Key findings/Evidence Standard met? Those service users whose care was case tracked and other service users commented that the staff team provide support and assistance with personal hygiene in accordance with their preferences and routines. All three files contained manual handling risk assessments and action plans that were reviewed regularly. The equipment required was identified on the assessment. Each file contained a tissue and nutritional assessment and these was reviewed in accordance with the guidance. Appropriate referrals are made to medical professionals, when required. Appropriate equipment was provided in the home for those service users who required pressure relieving seats and mattresses. Service users weight was monitored and recorded monthly or weekly depending upon the needs of the service user. Within the general risk assessment an assessment and information is collated in relation to falls. The Registered Manager is currently developing a separate falls risk assessment. Information about GP, dentists, opticians, chiropodists, and district nurses visits was recorded in files, and on individuals daily log sheets. Service users confirmed that they receive the involvement of health professionals as part of there plan care.. All accidents are recorded in the accident book, and this information is also recorded is recorded on the daily log sheet and on a more in-depth service specific accident form which is located on the individuals file.Grangewood LodgePage 18 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? The medication records and medication for the three residents identified for case tracking purposes were examined. These were seen to be generally in good order. There were photos available on the Medication Administration Record (MAR) for identifying service users. There was evidence on the MAR chart that all medication has been checked in. All medication that been removed from the Monitored Dosage System had been signed for. The appropriate code had not always been recorded on the MAR chart for medication that had not been given. A number of medications had been handwritten onto the MAR charts. These entries had not been signed and dated by two members of staff. Eye preparations were labelled on the inner container. Eye preparations, which have a limited expiry once opened, were marked with the date of opening. A refrigerator for medication was used, and the temperature was monitored and recorded twice daily. In the three files case tracked there was a medication declaration form identifying the level of support service users wanted with the administration of their medication. Service users had three options i.e.; to self medicate all medication or only certain ones, or to request for the staff team to take full responsibility. Service users signed the form applicable to their individual needs. The Registered Manager informed the inspector that medication policies are in place including a homely remedies policy. The inspector did not examine these on this occasion. Staff receive training provided by their dispensing pharmacist. The inspector informed the Registered Manager that an assessment of medication competence must be developed and completed on all staff members that administer medication. The home had a list of staff members authorised to administer medication with a record of their approved initials. The medication blister pack is given to the service user or their representative when they go out for a social leave.Grangewood LodgePage 19 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Those service users whose care was case tracked as part of case tracking methodology, and other service users who spoke with the inspector indicated that the staff team respect their privacy and dignity. Service users commented that the staff team routinely knock on their bedroom doors prior to entering. Information about preferred form of address was recorded, and service users commented that the staff team refer to them in a manner that is acceptable to them. The inspector observed a good rapport between service users and staff. There is both male and female staff that supports service users in personal care tasks. Service users are given the choice of who they would like to support them, and the Registered Manager is in the process of developing a policy on gender and personal care issues. The Commission for Social Care Inspection received 20 completed service user comment cards. All of the service users who completed these comment cards indicated that staff treated them well, that their privacy was respected and that they feel safe living at Grangewood Lodge. The Commission for Social Care Inspection also received 10 completed relative/visitor comments cards. All relatives indicated that they were satisfied with the overall care provided. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? In the three care files case tracked there was information relating to service users preferred arrangements following their death. The pre-inspection questionnaire indicates a policy is in place, but this was not examined on this occasion. The Registered manager confirmed that in the event that a service user becomes ill or is dying, they would be allowed to remain in the privacy of their room. Relatives and visitors would be offered support during this difficult time. The staff team would work with external agencies to ensure the service user recives the support and treatment required. The inspector spoke with relatives who confirmed that the staff team keep them informed of any changes in the service users health. There was evidence in service user daily logs, of prompt medical referrals when a service user becomes ill. The information supplied on the pre-inspection questionnaire indicated that 4 service users have died at Grangewood Lodge in the previous 12 months, and five service users died in the hospital.Grangewood LodgePage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 4 Key findings/Evidence Standard met? Preferred routines of daily living and preferred activities were identified within care plans. Service users reported that routines were flexible. Activities are planned on a regular basis. Grangewood Lodge employs an activities co-ordinator for up to 17.5 hrs a week. Service users who spoke with the inspector spoke positively about the co-ordinator and the activities provided. Service users comments included; shes lovely and does good activities shes really kind and patient. The co-ordinator completes a programme of activities throughout the month, which is then displayed in the reception area. Activities include; gardening, reminisance sessions, card and board games, cooking, etc. Service users also have a monthly entertainer visit every month and service users also get the opportunity to go out into the community to access the shops, gardening centres, theatres etc. On the day of the inspection service users attended a bingo session. In preparation for Christmas service users have been involved in making Christmas decorations, and a memorial tree has also been set up, which service users felt was an excellent idea to enable them to remember loved ones. Service users write a star and place it on the tree in remembrance. The hairdresser visits the home twice a week, and service users spoke positively about this service provision. The Commission for Social Care Inspection received 20 completed service user comment cards. 19 Service users who completed these comment cards indicated that the suitable activities were provided, whilst 1 service user indicated that suitable activities were not provided. Due to the positive comments received from service users about the activities provided and the motivation and commitment from the co-ordinator and the staff team in organising functions and raising funds for the service users amenities fund a score of 4 has been awarded on this occasion.Grangewood LodgePage 21 Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? Service users spoken to informed the inspector that they are able to see visitors either in communal areas or in the privacy of their own room. Information about visiting was included in the Statement of Purpose / Service User Guide. Relatives informed the inspector that they are always made to feel welcome by the staff team when they visit, and that refreshments are offered to them. Relatives spoke positively about their relationship with both the staff team and the manager. Grangewood Lodge has positive links with the community, who attend functions organised at the home for example; Christmas fetes. Relatives and visitors informed the inspector that the home has a good reputation in the surrounding community as being a good home. The Commission for Social Care Inspection also received 10 completed relative/visitor comments cards. All relatives who completed the comment cards indicated that they are made to feel welcome when they visit the home and they are able to visit their relative/friend in private. All relatives also indicated on the comment cards that they were kept informed of important matters affecting their relative, and one relative chose not to answer this question. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Service users spoken to confirm that they are enabled to make choices about their daily lives, in that they choose how to spend their days, join in with activities. The aims and objectives and principles of care outlined in the Service User Guide include promoting service users autonomy and choice. Staff who spoke with the inspector confirmed that they promote service users independence and encourage service users in their mobility, and to be self-managing. Service users supported this and confirmed that they encouraged to do things for themselves. Service user records were maintained securely in the office. Service users and relatives spoken to by the inspector were aware of their right to access their records and the policies and procedures of the home. In the care files examined there was an inventory of service users belongings brought into the home on their admission.Grangewood LodgePage 22 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The inspector joined the service users in one of the dinning rooms for their lunch. The menu for the day is displayed in the dinning areas and includes a three-course lunch with two options available for all courses. The meals for that day corresponded with the planned menu, which is rotated every four weeks. The mealtime was very relaxed and unrushed, and service users are able to choose where they would like to eat their meal. Service users who spoke with the inspector stated that the food is always excellent and that choices are always offered. Relatives also spoke positively of the food and comments made to the inspector included The quality of the food is good. The food is served in tereans to enable service users to help themselves to their desired amount. Hot and cold drinks were available throughout the day. A tour of the kitchen area was undertaken as part of this inspection. Levels of food stocks were satisfactory. There was a good supply of fresh fruit for service users. Fridge and freezer temperatures were monitored and recorded twice daily. Catering staff have received training in Food Hygiene. The cook had a good knowledge of the dietary needs of the service users, and their likes and dislikes. Feedback is gained from the service users by the staff and cook The catering staff consult with the service users following the meal in order to gain feedback on the food provided. The Commission for Social Care Inspection received 20 completed service user comment cards. 19 service users who completed the comment cards indicated that they liked the food provided at Grangewood Lodge, 1 service user indicated that they did not like the food, provided.Grangewood LodgePage 23 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 5 X X X 0 0 100 3 Key findings/Evidence Standard met? Grangewood Lodge has a complaints procedure, which details the timescales within which, a complaint will be responded to. The procedure contained details on how to contact the Commission for Social Care Inspection. The Registered Manager provided the above information in the pre-inspection questionnaire. The 5 complaints were made by service users, and concerned informal matters. The inspector examined the documentation and all complaints had been recorded and action taken in accordance with the complaints policy. Service users are informed of the procedure for making complaints in the Statement of Purpose and Service User Guide, and the procedure is displayed in several areas around the home. The Commission for Social Care Inspection received 20 completed service user comment cards. All service users indicated that they knew who to speak to if they were unhappy with their care. Of the 10 completed relative/visitor comments cards, all of the relatives indicated that they were aware of the complaints procedure.Grangewood LodgePage 24 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? Service users informed the inspector that they are actively encouraged to participate in the local elections. Service users stated that they can either complete the postal votes or be supported to attend the polling stations. Information on advocacy services is available in the reception area.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? A copy of the Local Authority Protection of Vulnerable Adults procedure was in place, and is incorporated within Grangewood Lodges internal protocols, which include a Whistle blowing policy. Senior care staff have received training in these procedures. The Registered manager informed the inspector that more dates are being organised in order to send more staff members to complete the training. In discussions with the inspector staff demonstrated awareness of what to do in the event of a service user being exposed to a potentially abusive situation. The Registered Manager is aware of the POVA register and guidelines.Grangewood LodgePage 25 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The inspector carried out a tour of the building. Grangewood Lodge was well maintained and decorated throughout. The Registered Person continues to invest in the home, and certain areas have been redecorated within the last twelve months. The Registered Person is improving certain areas of the home on a rolling programme. Many service users and relatives commented on how homely, and welcoming the building is. The Registered Manger has a programme of maintenance and decoration. During the inspection of the kitchen area the inspector noted that both the kitchen floor and the stores floor are worn and need replacing. The inspector was informed that the kitchen floor is due to be replaced in Jan 2004. A gardener is employed to maintain the extensive grounds. Service users commented on how they enjoy the garden in the summer months, and the views of the garden from their bedrooms. The fire officer visited on 12/6/04 and made recommendations concerning the need for fire doors. The Registered Person is purchasing new fire doors as part of a rolling programme. The Environmental Health Officer visited on 1/8/03 and all requirements and recommendations have now been addressed.Grangewood LodgePage 26 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? Grangewood Lodge has a number of lounge and dining areas for use by service users. All areas of the building are accessible for service users, and were well utilised during the inspection. Service users had the option of sitting in a quiet area if they did not like high noise levels. Lighting in communal areas was satisfactory. Furniture in communal areas was domestic in nature and of good quality. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Service users have access to a range of toilet and bathing facilities. Toilets and bathroom areas were well decorated. The facilities were clearly marked, and all doors were fitted with privacy locks, and call systems. Service users have access to specialist bathing facilities, and aids and adaptations. The Registered Person continues to invest in the building and in upgrading the bathing facilities. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? Suitably qualified persons, including a qualified occupational therapist, have not assessed the premises and facilities. At the time of this inspection, the building was suitable for the service user group that the service it is intended for. Suitable aids and adaptations were provided throughout the building. The staff team have access to a range of equipment to assist with the moving and transferring of service users. Service users have access to a call system in all rooms, and grab rails are provided in corridor areas. Access to first floor was via a chair lift.Grangewood LodgePage 27 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES YES 26 16 2 2 26 00 0 2 03 Key findings/Evidence Standard met? Grangewood Lodge was registered before the introduction of the National Minimum Standards and Care Standards Regulations 2001. Grangewood Lodge continues to provide the accommodation it provided at 31st March 2002. Service users commented to the inspector that they thought their bedrooms `were lovely and `comfortable.Grangewood LodgePage 28 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? The rooms visited by the Inspector demonstrated that Service Users were encouraged to bring personal possessions, with them to the home, and bedrooms seen had been personalised to varying degrees. Service users commented that they liked their bedrooms and the lovely views, of the garden. . The Registered Person is in the process of purchasing furniture in accordance with this standard, to enable all service users to have the choice of being supplied with the furniture if they choose. Not all of the rooms have all the provisions provided and some service users have signed a declaration to state that they do not want certain provisions, but this has not yet been achieved for all service users. All Service Users bedroom doors were fitted with privacy locks and keys are available to service users if they wish to have them. Lockable storage space was provided for those service users who that wanted them.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and these needs of individual service users. 3 Key findings/Evidence Standard met? The home is centrally heated throughout. Radiators have guards fitted to ensure low surface temperatures The temperature of the hot water is controlled at all outlets accessed by the service users, and this monitored by the maintenance man who records all checks undertaken. Emergency lighting is provided throughout the home; regular checks are carried out and records completed. A Legionella risk assessment is in place.Grangewood LodgePage 29 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? Grangewood Lodge was found to be clean and free from offensive odours at the time of the visit. The domestic upkeep of the home is to a good standard. Service users spoke positively about the standard of cleanliness and comments made to the inspector included the home is always clean and smelling nice. Relatives also stated that the home was always clean. The inspector did not visit the laundry area on this occasion, but did speak to service users and relatives about the laundry service. Comments were mixed as some service users have had clothing misplaced after they have sent it to be washed. Relatives also confirmed that on occasion clothing is lost or misplaced. These comments were discussed with the Registered Manager who was aware of the problems. The Registered Manager informed the inspector that a new laundry person has recently been employed; therefore she hopes the service will improve. Other service users commented that the laundering service was satisfactory.Grangewood LodgePage 30 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 3 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 2 25 526.85 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 534.5 X X X0 15 8 Standard met? 3Grangewood LodgePage 31 The Registered manager in the pre-inspection questionnaire provided the information above. Grangewood Lodge staffing levels are in accordance with the residential staffing forum, which is a formula used to identify staffing levels based on dependency levels and occupancy numbers. Staff are on duty at peak times of the day. All senior staff employed were over 21 years of age, and no one was under 18 years old. Catering staff and domestic staff are employed over seven days. The Commission for Social Care Inspection also received 10 completed relative/visitor comments cards. 9 relatives indicated that in their opinion there are always sufficient numbers of staff on duty, and 1 relative commented that they did not always feel that sufficient numbers of staff were on duty. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 5 35 3 Key findings/Evidence Standard met? The above information was taken from the pre-inspection questionnaire. The inspector was informed that there is currently 8 staff members undertaking an NVQ level 2. There are currently 7 staff members who are qualified in First Aid.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? A recruitment and selection procedure was in place. The inspector examined three staff files. All new staff have had a Criminal Bureau check, and the Registered Person has processed all of the existing staff members criminal records bureau checks and these have been returned and are on the staff files. The files examined contained all of the information as required by Schedule 2. All staff members are given a copy of the General Social Care Council code of conduct and practice at the beginning of their employment, and staff members sign to verify they have received a copy. Staff members are given Terms and Conditions of employment and job descriptions. A copy of the amended regulations was given to the Registered Manager. In accordance with these changes the staff application form needs to be updated in order to request an applicants full employment history and written explanation of any gaps in employment.Grangewood LodgePage 32 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? The Inspector examined the staff training files. Each staff member had a training programme, and an action plan for identified training needs. Certificates were available for courses attended. The Registered manager informed the inspector that all new staff complete induction training. The inspector examined the induction package, which is service specific. The inspector and the Registered Manager had a discussion concerning the induction and whether it meets National Training Organisation (NTO) specifications. The Registered Manager agreed to check this. All staff who spoke with the inspector confirmed that they receive all the required mandatory training, and service specific training. The Registered Person informed the inspector that all staff receive three paid training days each year.Grangewood LodgePage 33 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The Registered manager has many years experience of working with older people. The responsible manager has completed a NVQ Level 4, and stated that she regularly updates her knowledge and skills by attending training courses. The inspector spoke with the senior members of staff who confirmed that there are clear lines of accountability within the home. The Registered Person completes unannounced inspection visits in accordance with areas identified in regulation 26.Grangewood LodgePage 34 Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 4 Key findings/Evidence Standard met? Staff who spoke with the inspector commented that the Registered Manager is approachable and creates an open, positive and inclusive atmosphere. Staff commented that she is down to earth and laid back and confirmed that when there is a need the Registered Manager will assist staff members in there work with the service users. Service users commented that the Registered Manager was approachable, nice friendly and dealt with issues appropriately. Relatives who spoke with the inspector also confirmed that she was approachable, and how she makes the process of moving someone into a home a positive one. The Registered Manager has an `open door policy at all times for all people in the home. The Registered Manager works alongside the staff team in order to maintain links with the staff and service users. The Registered manager is committed to equal opportunities, and in staff development. Staff members are motivated to take on additional responsibilities in order to learn more skills. The Registered Manager delegates key roles to the senior staff and then rotates these roles to enable all seniors to become familiar with the different aspects of the management role and administration. Throughout the inspection relatives and service users commented positively about the Registered manager and the way in which she manages the home. Based on these positive comments a score of 4 has been awarded on this occasion. Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? The Registered Manager undertakes quality assurance monitoring, this includes: a Quality Assurance questionnaire, which is sent to all service users and their relatives in order to gain comments on the service provision. An example of the questionnaire used is in the Service User Guide along with comments made. Grangewood Lodge request feedback from service users and relative during the review process, and on a day-to-day basis. The home has received letters complimenting the staff team on the quality of the service provision provided. The Registered Manager and the senior team regularly undertake audits of all the systems within the home. Service users meeting are held regularly and based on the comments received; systems and procedures have been improved. As previously stated, the Commission for Social Care Inspection received 20 completed service user comment cards and 10 competed relative/visitor cards. The comments made on these are included with the relevant standard in the report.Grangewood LodgePage 35 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? Grangewood Lodge had a copy of the public liability insurance certificate, and this was displayed. Information is available to service users concerning the homes insurance policy.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 2 X X3 Key findings/Evidence Standard met? The Registered Manager provided the above information in the pre-inspection questionnaire. The money held in safekeeping for those service users whose care was case tracked using case tracking methodology was checked. Service users money was kept separate and the records and amounts were cross-referenced and were satisfactory. Two staff signatures were on the records following all transactions. The inspector was informed that all the finances are audited regularly. Service users finances are locked away securely in the safe.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? The Registered manager reported that all staff receive supervision approximately every two months. The Registered manager is responsible for supervising all senior members, and then the senior members supervise the care staff. The inspector examined staff files, these demonstrated that supervision covered all the areas as required by the National Minimum Standards, and also included an assessment of practical tasks, based on the staffs role. Staff confirmed that they receive both formal and informal supervision; a policy on supervision was in place. All staff received yearly staff appraisals.Grangewood LodgePage 36 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? There was evidence in the care files, case tracked to support that service users were actively involved in the development of their care plan, and that they have access to their records. There was evidence to support that the senior keyworker supervisor routinely monitors the standard of Service Users records including the daily records. The home had a policy regarding access to personal data in accordance with the Data Protection Act 1998. Records are stored in the main office, which can be locked when not in use. All records were being kept in respect of each Service User as required by, and detailed in Schedule 3 of the Care Homes regulations 2001. The information supplied in the pre-inspection questionnaire indicated that all of the required policies and procedures have been put in place. The Registered Manager has updated all of the policies and procedures in January 2004. The policies and procedures was not checked during this inspection. Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The training records examined confirmed that the staff team receive mandatory training as a rolling programme. The staff team receive in-house training, which meets the National Training organisation specifications. All equipment had been serviced with the specified time scales. Protective clothing was provided and used by staff. The accident records were cross-referenced to the daily logs and found to be satisfactory. General risk assessments had been completed. There was evidence of staff receiving training in safe working practices such a fire training and moving and handling. The Registered Manager has completed a Fire Risk Assessment in Nov 2004. A sample of the maintenance records were checked i.e. gas, electric, hoist, pat testing etc; and all were found to be satisfactory.Grangewood LodgePage 37 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateC. Williams G. GorsuchSignature Signature SignatureGrangewood LodgePage 38 Public reports It should be noted that all CSCI inspection reports are public documents.Grangewood LodgePage 39 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleGrangewood LodgePage 40 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 10 January 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YES D.2Action plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNOYESOther: enter details here Grangewood LodgePage 41 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Grangewood Lodge confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Grangewood Lodge am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Grangewood LodgePage 42 Grangewood Lodge / 7th December 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000019996.V191450.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!