Inspection on 28/01/08 for Grantley Court Nursing Home

This inspection was carried out on 28th January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grantley Court Nursing Home 01/06/06

Grantley Court Nursing Home 01/11/05

Grantley Court Nursing Home 18/07/05

Grantley Court Nursing Home 22/11/04

Grantley Court Nursing Home 27/07/04

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

CARE HOMES FOR OLDER PEOPLE Grantley Court Nursing Home 22 York Road Sutton Cheam Surrey SM2 6HH Lead Inspector Barry Khabbazi Key Unannounced Inspection 28th January 2008 10:30a X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grantley Court Nursing Home DS0000044083.V357872.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grantley Court Nursing Home Address 22 York Road Sutton Cheam Surrey SM2 6HH 020 8661 0273 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) cooppencare@yahoo.co.uk Mr Soondressen Cooppen Anita Dusoruth Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0) Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th June 2007 Brief Description of the Service: Grantley Court is a home registered to provide nursing care, for up to thirty adults over the age of sixty-five, with dementia or other mental health disorders. The Registered Provider, Mr Coopen, who also owns three other homes in the area, bought the home in July 2003. The home is a large detached house situated in a quiet area in Cheam, well served by public transport links, there is off street parking to the rear of the property. Accommodation is provided in twelve single and nine double bedrooms all of which have been fitted with washbasins, some have en-suite facilities. There is a large open plan lounge and separate dining room, a small smoking area has been provided for residents use. There are sufficient numbers of toilet facilities conveniently located throughout the home and kitchen and laundry facilities are clean and well equipped. There is a pleasant back garden which includes flower beds, fruit trees and a patio area which is well maintained and enjoyed by residents in the summer months. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key Standards identified throughout this report were assessed at this inspection. This inspection also focussed on following up on previous requirements and recommendations, and any new issues arising. This inspection was unannounced. The manager and administrator were interviewed, time was spent with the service users, and records, policies, care plans, and the building were also examined. An improvement in some standards was noted at this inspection. 10 of the 21 previous requirements have been met and many others were in the process of being met. 3 new requirements were set as a result of this inspection. As there are a number of requirements still to be fully met, more urgent requirements that will facilitate protecting the service users from harm have been highlighted as prioritised in the requirement list to assist the manager in knowing which ones to action more urgently. The Commission does not usually carry requirements over from one inspection to another. To recognise the improvements that have been made further action will not be taken at this time regarding previous requirements that remain unmet. However, if the existing unmet requirements that have been highlighted as priority requirements have not been met by the next inspection, the Commission will consider what further action is needed on our part to achieve compliance. The manager demonstrated a commitment to meet the requirements set and the inspector is therefore confident that standards will continue to improve. What the service does well: It is expected that as the number of unmet requirements continues to decline, that areas of good practice that are above the minimum standard will be more easily identified so they can be recorded here. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The service user plan needs to continue to be updated so that they all include assessments of social care needs. This helps staff provide more relevant activities. Care plans need to be more person centred and demonstrate how all care needs will be met. To avoid unnecessary interventions, risk assessments need to be individualised and detail appropriate interventions. Wound care needs to be recorded more accurately to be in line with current guidance and promote good practice. End of life arrangements and preferences are being sought but this needs to be completed to ensure that all residents’ wishes regarding this are known. Activities are provided but these need to be developed to be more in line with resident choice. More thought is required to improve the institutional practices at mealtimes for example almost all residents were using spoons to eat their lunch and they all had the same type of drink. The in-house adult protection procedure must include reference to the Local Authority multi agency procedures. This is needed to ensure that the home follows the same procedures as the local authority which better protects residents. The service users were supported by a staff group where 50 or more have the required qualifications however following staff leaving this has fallen below 50 now. Achieving this raises the quality of staff, their knowledge and their practices. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 7 Staff receive induction and foundation training but this needs to meet National Training Organisation Standards to ensure that they are fully inducted. There is a quality assurance system that involves the residents, but this needs to be developed to provide feedback to them, to allow them to be involved in improvements and measure improvements in the home for themselves. 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. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User guide do inform people about the details of the service provided although this needs more specific updated information about staff qualifications when the next update occurs. Prospective service users’ needs are assessed before they start at the home to ensure that all needs are known by the staff. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 10 EVIDENCE: The last inspection report contained the following requirement under Standard 1: The registered person must ensure that the Statement of Purpose and Service User guide comply with the regulations and Schedules. This had been updated by the time of this inspection but one very minor omission remained. The Statement of Purpose did not specify how many staff were employed and their specific qualifications. Only a general statement was available about qualifications. To be proportional the requirement will be seen as met and a new recommendation will be set as follows: The next updating of the Statement of Purpose should specify the actual number of nurses and care staff and how many have which qualification. The last inspection report contained the following requirement under Standard 3: The registered person must ensure that assessments are completed fully and contain all relevant information, including that from other professionals. Assessments for new service users were examined and these contained all the relevant initial assessment material, including the placing authorities assessment and care plan. This requirement is therefore currently met. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9, 10 and,11. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Plans of care are regularly updated but still do not record all needs and therefore do not fully inform staff about all a resident’s needs. Service users are usually supported to make decisions about their lives although social needs have not been fully assessed. This means staff do not know about these needs and preferences and can not support service users fully about decisions about their lives in this area. Service users are not always protected by the homes health monitoring procedures. Service users are protected by the home’s medication procedures. Risk assessments are not available for all restraints and do not contain all the information required. Including this information could reduce unnecessary restrictions of liberty for the service users. Service users are generally treated with respect and their privacy is maintained. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 12 EVIDENCE: The last inspection report contained the following requirement under Standard 7: The service user plan must included assessment of social care needs. The manager had started to work through the care plans to update them with the information required. This process had started but had not concluded for all service users yet, the requirement will therefore remain until fully met. The last inspection report contained the following requirement under Standard 7: The registered person must ensure that specific details are present in care plans in order that care can be carried out. As mentioned above the manager had started to work through the care plans to update them with the information required. This process had not concluded for all service users yet and was demonstrated by one file recording ‘to provide a good level of personal care’ this is not specific enough and details of how to provide the care and at what level were not present yet. The requirement will therefore remain until met. The last inspection report contained the following requirement under Standard 7: The registered person must ensure that care plans are person centred and demonstrate how care needs will be met. As mentioned above the manager had started to work through the care plans to update them with the information required. This process had not concluded for all service users yet. The requirement will therefore remain until fully met. The last inspection report contained the following requirement under Standard 8: The registered person must ensure that risk assessments are individualised and detail appropriate interventions. Risk assessments were sampled and found to still need to be more specific. In addition there were no risk assessments for some restraints like the use of cot sides. The requirement will be re-written to clarify the remaining shortfalls as follows: The registered person must ensure that risk assessments are individualised, detail appropriate interventions, and are available for all restraints and restrictions of liberty needed to protect a service user. The last inspection report contained the following requirement under Standard 8: The registered person must ensure that wound care is recorded accurately in line with current guidance. There was still a need to record better details of wound care, for example, one file sampled had records of a pressure sore but no details of the size of the pressure sore. The size is needed for monitoring to occour effectively. This requirement will remain until met. The last inspection report contained the following requirement under Standard 8: A risk assessment and a manual handling assessment must be carried out Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 13 and recorded for each service user. This has now occurred and this requirement is now therefore met. The last inspection report contained the following requirement under Standard 9: The registered person must ensure that the medication policy is reviewed and up dated. This policy had been reviewed and updated. This requirement is now met. Service users are registered with a local GP practice and have access to other NHS facilities as necessary such as a dentist, optician, chiropodist, and “well woman” clinic. District nurses and other healthcare professionals attend when required. Evidence was seen of regular monitoring of service users’ health. The service users are registered with a local G.P and have regular check ups. A record of all appointments and check ups are kept. The manager demonstrated knowledge of the health status of individual service users. All staff who administer medication have had approved medication training. Medication profiles and clear medication administration record sheets were seen in records sampled. Medication and the M.A.R sheets are kept. Service users were seen to be treated with respect and personal care was carried out in a manner that promoted the service users’ privacy. The last inspection report contained the following requirement under Standard 11: The registered person must ensure that residents’ end of life wishes are documented and acted upon. The manager had started to work through the residents’ files to update them with the information required. Relatives and care managers had been contacted to provide the information required. This process had not concluded for all service users yet. The requirement will therefore remain until fully met. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 12,13,14,and,15. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although there was evidence of activities in the home occurring, activities need to be better linked to the residents’ choices and preferences. Service users are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Service users are not fully supported to exercise choice and control over their lives. The food provided is sufficient in quantity, but choices of food need to be better recorded, and support at mealtimes needs to be more sensitive. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 15 EVIDENCE: The last inspection report contained the following requirement under Standard 12: The registered person must ensure that activities are developed in line with resident choice. As stated under Standard 7, care plans did not contain assessments of social care needs. Without this assessment information there is limited information to insure activities are in line with residents preferences and choice. The requirement therefore remains. The last inspection report contained the following requirement under Standard 14: The registered person must ensure that residents’ choice in all aspects of their daily life is evident. Again with out choices being identified it is difficult to show how choices are sought and acted apon. In addition choices were seen to be removed at lunchtime with all residents having the same drink and most using spoons to eat their lunch. This requirement therefore remains. The last inspection report contained the following requirement under Standard 15: The registered person must ensure that mealtimes are a social event. This is not required under the standards, and choice about not eating with other service users is supported under the standards. This requirement is therefore withdrawn. However staff were observed feeding service users from a standing position and also to feed two service users at one time. This does not promote dignity or provide care in a sensitive manner which is required under the standards. The following new requirement is now therefore set to address this: Staff must feed service users from a seated position and engage with them during the process unless a risk assessment shows otherwise. It was difficult for the inspectors to know what meals were on offer for that day. The following recommendation is therefore set. A pictorial menu and an orientation white board recording date day and menu choices for the day should be implemented. There were some positive interactions between staff and residents; a member of staff asked a resident if they required assistance in a gentle manner and a member of staff reassured and calmed a distressed resident in a sensitive and effective manner. Records showed that suitable arrangements are in place to enable service users to maintain good links with their families and friends. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 16 Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18 and 20: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be confident their complaints will be listened to and acted upon where appropriate. Service users are generally protected from abuse or self harm through the home’s protection policies and procedures and by these being known, although as the home’s abuse allegation reporting procedures are contrary to the local authority’s adult protection procedures, service users are not fully protected in this area. EVIDENCE: The last report recorded that ‘The home has received no complaints. Both survey respondents knew how to make a complaint. It was noted that there were two different complaints policies within the home. One was in the correct format and complied with the Regulations, but the other in the Service User Guide did not detail timescales for response.’ The following requirement was then set: The registered person must ensure that the complaints policy is updated. The policy had been updated to contain the information required. This requirement and the complaints standard are both now met. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 18 The home has a Gifts Policy, a Wills policy, a Whistle Blowing policy, and a Restraints policy and guidance. The Gifts Policy does preclude staff from receiving gifts and does preclude staff from being involved in the making of, or from benefiting from service users’ wills. The last inspection report contained the following requirement under Standard18: The in-house adult protection procedure must include reference to the Local Authority multi agency procedures. This policy was examined. It stated that any allegations of abuse would be first be investigated in house and then only passed to social service adult protection if the service user agreed to this. These statements are contrary to the local Authority multi agency procedures. In fact allegations must not be initially investigated in house and must be all referred to adult protection who will make the decision about who will investigate. In addition the service user has a choice about whether they wish to bring charges but not about whether this information is passed to adult protection. This requirement therefore remains unmet and in force. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 19 and 26: Quality in this outcome area is, good,. This judgement has been made using available evidence including a visit to this service. The environment and furniture generally meet the residents’ needs, and the environment does generally promote the residents well being. The home is hygienic and clean. This environment therefore facilitates the service users’ health and emotional well-being. EVIDENCE: The premises were and clean, and free from offensive odours. There was suitable lighting and ventilation. The grounds were well kept. The overall condition and décor of the home was reasonable. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 20 The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. Protective clothing was observed to be present. Laundry facilities have easily cleanable non-permeable floors and walls. The last inspection report contained the following two requirements under Standard 19: 1, The registered person must ensure that a planned programme of refurbishment and redecoration is submitted to the CSCI 2, The cracked pane of glass in the laundry must be replaced. A planned programme of refurbishment has been implemented, there is a maintenance book showing when issues are identified and when addressed. This showed a timely response. The pain of glass in the laundry had been replaced. Both these requirement are therefore now met. In addition there are new carpets on the ground floor, and new dining room chairs and new reclining chairs. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Duty rota indicate that there are adequate numbers of staff to meet needs. The service users were supported by a staff group where 50 or more had the required qualifications however following staff leaving this has fallen below 50 now. Achieving this raises the quality of staff, their knowledge and their practices. The home’s recruitment procedures protect the residents through vigorous staff vetting. Staff receive induction and foundation training but this needs to meet National Training Organisation Standards to ensure that they are fully inducted. EVIDENCE: The last inspection report recorded that the duty rota and observation on the days of the site visits indicated that there are adequate numbers of staff to meet needs. This was also the case at this inspection. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 22 The service users were supported by a staff group where 50 or more have the required qualifications however the manager informed me that following staff leaving this has now fallen below 50 . The following new requirement is set to address this under Standard 28: 50 of the total staff team need to have a NVQ2 or above. All elements of Schedule 2 {staff files} were available for inspection. Staff recruitment documents were examined and these included CRB checks, references and proof of identification. No shortfalls were identified in the staff recruitment process. The last inspection report contained the following requirement under Standard 29: The registered person must ensure that there is a clear recruitment policy, which complies with the regulations. The recruitment policy had been updated and this requirement is now met. The last inspection report contained the following requirement under Standard 29: The registered person must ensure that training is evidenced when undertaken. Records for training are now recorded and this requirement is now therefore met. There is an induction process but this does not meet National Training Organisation specifications and targets. The following new requirement is set under Standard 30 to address this: An induction within the first six weeks followed by foundation training within the first six months must be completed for all new staff and this must be to National Training Organisation specifications and targets. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is managed by a person with appropriate qualifications and experience. There is a quality assurance system that involves the residents, but this needs to be developed to provide feedback to them, to allow them to be involved in improvements and measure improvements in the home for themselves. Service users’ financial interests are guarded. The home generally promotes the health and safety of the residents, so that practices and the environment do not place their health and safety at risk Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 24 EVIDENCE: The current registered manager has the required NVQ 4 Registered Manager’s award and is suitably experienced to manage the home. The last inspection report contained the following requirement under Standard 31: The registered person must ensure that the manager is supported to develop their role. The manager informed the inspector that she had received appropriate support including training materials. This requirement is met. The last inspection report contained the following requirement under Standard 33: The registered person must ensure that there are satisfactory quality assurance systems in the home. There is a quality assurance system that involves the residents, but this needs to be developed to provide feedback to them, to allow them to be involved in improvements and measure improvements in the home for themselves. This could be done by collating all the quality assurance information {from complaints, provider visits and plans, service user questioners, etc} into one document { an annual development plan} this document could then be presented to service users to inform them of quality plans and allow them to monitor progress by presenting an updated version annually. This requirement therefore currently remains in force. Procedures are in place to protect service users’ money and no anomalies were identified at this inspection. All of the health and safety policies and procedures relevant to this standard were seen to be present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. The testing of systems required in Standard 42 were also present and inspected. These included fire fighting equipment testing, fire warning testing, Portable Appliance Testing, 5-year wiring testing and Bacterial analysis and testing of the water supply. One minor shortfall was however identified. There was a suspected asbestos product lining the door of the cupboard on the top floor to the hot water tank. Legally it does not matter whether this is actually asbestos, as it looks like asbestos it should be treated as a suspected asbestos product. This involves getting it sampled and tested to ascertain if indeed it is asbestos and what type. The product then needs to be labelled accordingly and a risk assessment made. If it is not asbestos it should be labelled as such. If it is asbestos the type and condition will dictate what action is required. This can range from no action, to sealing it with a special paint or professional and safe removal. The following new requirement is now set to address this: Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 25 The home must provide evidence, that any suspected asbestos products within the home have been professionally identified, then labelled, sealed and left, or safely removed as risk assessment indicates, and under Health and Safety regulations. {See also, Regulation 4 of the Control of Asbestos at Work Regulations 2002.} Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered person must ensure that care plans are person centred and demonstrate how care needs will be met. {unmet from the previous inspection } The registered person must ensure that specific details are present in care plans in order that care can be carried out. {unmet from the previous inspection} {Priority requirement} The service user plan must included assessment of social care needs. {unmet from the june 2006 inspection} The registered person must ensure that risk assessments are individualised, detail appropriate interventions, and are available for all restraints and restrictions of liberty needed to protect a service user. {unmet requirement extended} {Priority requirement} The registered person must ensure that wound care is recorded accurately in line with DS0000044083.V357872.R01.S.doc Timescale for action 30/06/08 2. OP7 15 30/03/08 3. OP7 15 30/06/08 4. OP8 13 (4) (c) 30/03/08 5. OP8 17 (1) (a) & 3 (3) (k) 30/03/08 Grantley Court Nursing Home Version 5.2 Page 28 6. OP11 12 (1) (b) 7. OP12 16 (2) (m) & (n) 8. OP14 12 9. OP15 12[4] 10. OP18 13 11. 12. OP28 OP28 18(1)a 18(1)c 13. OP33 24 current guidance. {unmet from the previous inspection} {Priority requirement} The registered person must ensure that residents end of life wishes are documented and acted upon. {unmet from the previous inspection} The registered person must ensure that activities are developed in line with resident choice. {unmet from the previous inspection} The registered person must ensure that residents’ choice in all aspects of their daily life is evident. {unmet from the previous inspection} {Priority requirement} Staff must feed service users from a seated position and engage with them during the process unless a risk assessment shows otherwise. {Priority requirement} The in-house adult protection procedure must include reference to the Local Authority multi agency procedures. {unmet from the previous inspection} {Priority requirement} 50 of the total staff team need to have a NVQ2 or above. An induction within the first six weeks followed by foundation training within the first six months must be completed for all new staff and this must be to National Training Organisation specifications and targets. The registered person must ensure that there are satisfactory quality assurance systems in the home. {unmet from the previous inspection} DS0000044083.V357872.R01.S.doc 30/06/08 30/06/08 30/03/08 30/03/08 30/03/08 30/06/08 30/06/08 30/06/08 Grantley Court Nursing Home Version 5.2 Page 29 14. OP38 The home must provide evidence, that any suspected asbestos products within the home have been professionally 13[3] identified, then labelled, sealed 13[4]a,b,c and left, or safely removed as risk assessment indicates, and under Health and Safety regulations. {Priority requirement} 30/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP15 Good Practice Recommendations The next updating of the Statement of Purpose should specify the actual number of nurses and care staff and how many have which qualification. A pictorial menu and an orientation white board recording date day and menu choices for the day should be implemented. Grantley Court Nursing Home DS0000044083.V357872.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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