Inspection on 27/09/06 for Hall Grange

This inspection was carried out on 27th September 2006.

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

Hall Grange 31/07/07

Hall Grange 07/02/06

Hall Grange 28/10/05

Hall Grange 14/02/05

Hall Grange 10/01/05

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

CARE HOMES FOR OLDER PEOPLE Hall Grange 17 Shirley Church Road Shirley Croydon Surrey CR9 5AL Lead Inspector Diane Thackrah Key Unannounced Inspection 27th September 2006 9:20am 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 Hall Grange DS0000025787.V310860.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. Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hall Grange Address 17 Shirley Church Road Shirley Croydon Surrey CR9 5AL 020 8654 1708 020 8654 4982 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) home.fxg@mha.org.uk Methodist Homes for the Aged Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Hall Grange is owned by the ‘Methodist Homes for the Aged’ (MHA) a voluntary Christian organisation that specialises in caring for older people. The home is registered with the Commission to provide residential accommodation and personal support for up to 36 older adults, i.e. Aged 65 and over. Situated in Shirley, a residential suburb a few miles to the east of central Croydon, the home is well served by local shops and bus links. At this present time the premises, which is built over two floors, comprises of 36 single occupancy bedrooms, all with en-suite toilets; a main lounge with a small conservatory attached and built-in kitchenette; a large open plan dining room on the first floor, which has also been supplied with a kitchenette; a hairdressing room; laundry facilities; and a well equipped kitchen. There are sufficient numbers of toilet and bathing facilities located throughout the house. The garden at the rear is extremely well maintained and beyond the immaculately kept lawn is the ‘William Wilks Wilderness’, a protected environmental site that contains a wide variety of rare trees and plants. There is amble space for parking vehicles at the front of the building. A copy of the service’s Statement of Purpose and Service User Guide can be obtained on request from the Registered Provider. Fees for the home at the time of writing range between £488.00 and £544.00 per week and there are no additional charges. Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 27th September 2006 between 09.20 and 17.00. A partial tour of the premises took place and care records were examined. Observations of care practices also occurred. The Manager and four staff members were spoken with; as were ten service users and one volunteer. The views of six service users and eight relatives have been received via comment cards. The views of these people will be reflected in this report. What the service does well: This is a home were service users, in general, have their needs met. There was positive feedback from relatives about the care that their family members receive. One visitor felt that their father had been made very welcome in the home and treated kindly, gently and respectfully. Another visitor said that they were very satisfied with the care their relative received in the home. All relatives said that there are enough staff members and good opportunities for consulting with them. There was positive feedback from some service users about the care that they received, and the home in general. One service user said, “I like it here, its all good” Another said “We always have a choice at meal times” and another said, “I am happy here” Service users seen in the home appeared happy and content. There are, in general, adequate arrangements for planning care and for ensuring that service users have access to health and social care professionals. Staff members were caring and were available for service users during this inspection. There are good arrangements for ensuring that service users have access to social and recreational activities. Visitors to the home are encouraged and structured activities are facilitated. Service users have opportunities to exercise choice in relation to religious observance. Food is varied, healthy and enjoyed by service users. There are good arrangements for responding to complaints and for resolving issues before they become problematic. Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home is failing to meet National Minimum Standards in a number of areas and this is of concern. There has been an ongoing failure by the Registered Provider’s to address some Requirements set by the Commission for Social Care Inspection, and as a result, enforcement action may be taken against the home. There remains a need for the home’s Statement of Purpose to be updated in order to ensure that service users have all the information they need about the home. Care plans must be improved in order to ensure that staff members are clear about how service user’s need should be met. There is some poor practice in relation to handling medication, and there are currently no systems in place for auditing medication. Concerns have been raised during this inspection regarding one staff member who did not promote the safety of the service user group, by allowing a stranger into the home. Serious concerns have also been raised about the home’s ongoing failure to ensure that volunteers are thoroughly vetted before they work in the home, therefore placing the well being of service users at risk. There is a need to ensure that cleaning products are stored securely and to ensure that the emergency lighting in the home is safety checked on a regular basis. Fire doors must not be wedged open and there must be regular monitoring of fridge and freezer temperatures. Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hall Grange DS0000025787.V310860.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 Hall Grange DS0000025787.V310860.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 6. There remains a need to amend the home’s Statement of Purpose in order to ensure that service users have the information they need before making a decision to move into the home. There remain appropriate arrangements for obtaining information about the needs of service users before they move into the home, which allow these needs to be met. This is generally a user-focused service with service users and their carers participating in the process of planning for their care and for their changing needs. However, concerns about care standards in the home have been raised by some of those using the service as a result of this inspection, also, there has been a failure to meet a number of Requirements set at the last inspections of the home. These issues therefore put into question the ability of the home to protect the well being of service users. The home does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 10 EVIDENCE: It is disappointing that a Requirement made about the home’s Statement of Purpose has not been met. More specific information about the range of needs that the care home intends to meet must be included in its Statement of purpose/service users guide. A Repeat Requirement is made. More positively, the Statement of Purpose has recently been updated to reflect the increase in qualifications of the staff team. The home receives referrals through both private and care management arrangements. Assessment information was examined for the two most recent admissions. Assessments included a short social history, risk assessments and details about the service user’s personal and health care needs. There were also medical reports that had been obtained from the service user’s General Practitioner. There was documentation detailing that service users and some family members are fully involved in this process. There was positive feedback from a number of service users and their relatives about the home. One visitor said that their relative was “Made very welcome, treated kindly, gently and respectfully” in the home. The majority of relatives spoken with said that good care was provided in the home and there were sufficient opportunities for consultation. One service user spoken with said, “I like it here, its all good” Another said “We always have a choice at meal times” and another said, “I am happy here” However, a number of negatives comments about the home have been made during the inspection process. Comments were received from four service users about there being not enough staff members on duty at times. One service user said “you sometimes have to wait a long time for a staff member to answer the call bell” Another said “sometimes there is no one around” Two service users said of the staff “They ask you to sit at the dinner table, but keep you waiting there a long time before the meal is served” A visitor commented that that there was “poor communication between staff” and that “problems were not addressed quickly” There was one comment about a service user’s bedroom en suite facilities not being cleaned well. One service user said that they had been very disappointed about planning permission being refused regarding the repositioning of the home, as they wanted “better facilities” to live in. It of serious concern that the majority of the Requirements that were set at the last inspection of the home have not been addressed within agreed timescales. All Requirements must be met within the extended timescales in order to avoid possible enforcement action. A new manager has been appointed in the home, who has made an application to become registered with the Commission for Social Care Inspection. This manager presented as being competent and demonstrated a commitment to meeting the outstanding Requirements, and to addressing the concerns of service users and their Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 11 relatives detailed above. inspection of the home. Progress with this will be examined at the next Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The arrangements for ensuring that service users have their health, social and personal care needs met must be improved in order to ensure that all staff members are clear about how they should address service user’s needs and promote their wellbeing. The arrangements for handling medication must be improved in order to ensure that the wellbeing of service users is fully promoted and protected. A strong emphasis is placed on protecting the dignity, and respecting the privacy of service users ensuring that service users have a good quality of life. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Care plans for the two most recent admissions were examined. These contained some information about the service user’s personal, health and social care needs and there were risk assessments in relation to moving and handling. Care plans did not fully detail the needs of the service users, and how the staff team should address these needs. Care plans must include more Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 13 information about the service users needs including their preferences for washing, bathing, dressing, and cleaning their teeth and detail the action required by staff members to complete these tasks. A Requirement is made regarding these issues. Records were available detailing that care plans have been reviewed and updated as necessary, on a monthly basis. It was positive to note that a meeting between senior staff members in the home was taking place on the day of this inspection regarding the need for improvements in record keeping in the home. Care records seen detailed that service users have access to a range of health care professionals and that the home is proactive in arranging health care appointments. There were records detailing that service users are registered with a general practitioner and see opticians, district nurses and dentists as necessary. One service user spoken with said that they received good support from the staff members with their health needs, and felt confident that health appointments would be arranged for them as necessary. However, it is of concern that there has been a failure in the home to keep service user’s weight under review. The new Manager has recently implemented a system whereby service users are weighed monthly, with a record kept. Records of weight monitoring were available for only one month in relation to two service users who have lived in the home for over one year. A Requirement has not been made regarding this issue in view of the fact that weight monitoring now occurs, however, this issue will be monitored closely. There are policies and procedures in place for ensuring that medication is handled safely. One senior staff member confirmed that they had received training in the safe handling of medication and there was a record detailing all staff members who had received such training. The senior staff member demonstrated confidence in, and a good awareness of her responsibilities for handling medication safely. All medication was noted to be stored securely at the time of this inspection. The number of tablets contained in one bottle of controlled medication sampled at random matched the balance entered in the controlled drugs register for that particular drug. It was positive to note that some service users are being supported to maintain responsibility for their own medication. Medication Administration Records examined for six service users were accurate and up to date. One Medication Administration Record contained three gaps in recording. A Requirement is made regarding this issue. One Medication Administration Record detailed that a service user had been prescribed a painkiller four times daily, but this had only been administered three times daily. Service users must be administered all medication prescribed to them. Should a service user refuse prescribed medication over a prolonged period of time, this must be discussed with the General Practitioner. A Requirement is made regarding this issue. It is of concern that there have been no formal systems for auditing medication in the home. A senior staff member said that formal audits of medication are scheduled to commence in the home, and there was documentation to back Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 14 this up. These audits must occur in order to rectify errors without delay and to provide protection to service users. Staff members were observed to treat service users with respect and to uphold their dignity. Staff members were noted to knock, and wait for a response before entering service user’s bedroom. Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. There are good arrangements in place for ensuring that service users have access to social and leisure activities and for keeping in touch with their friends and family members. Meals are healthy and varied. Service users are therefore able to enjoy a lifestyle in accordance with their wishes. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users continue to have good opportunities for social and recreational activities. There was an activities programme displayed in the hallways on each floor of the home. These detailed that a light exercise class, and a ‘knit and Natter’ session would be facilitated in the home on the day of this inspection. Service users spoken with said that they were happy with the range of recreational facilities available to them. Ten service users were observed to be taking part in a gentle exercise activity at the beginning of this inspection, which was facilitated by the activities coordinator. All service users appeared to be enjoying this activity. One service user said that their relative visited them regularly in the home. Another service user said that there were a lot of volunteers who facilitated a wide range of activities, such as arts and crafts and outings. A volunteer was setting up a ‘table top’ shop in the home Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 16 at the time of this inspection. Religious services occur in the home on a regular basis and are open to all service users who wish to attend. Service users have opportunities for being involved in decision making in the home. One service user said that the new Manager had recently spent time chatting with them, and other service users regarding their views on the home. Another service user said that they were involved in drawing up a survey on food, which would be presented to service users. There was very positive feedback about food served in the home and a meal sampled was enjoyable and well presented. A weekly menu available detailed that meals provided are varied. There was a notice board detailing what meals would be served and that choices of meals were always available. Some service users spoken with said that they enjoyed food in the home. One service user said, “The food is usually very good” Another service user said, “We always get a choice” The cook said that there are currently two service users who have a specialist diet. There were records available in the kitchen detailing the special arrangements for food preparation for these service users, including records detailing that the home had worked with a dietician to put together a menu for one service user. There were suitable numbers of staff to assist service users at lunchtime. Hall Grange DS0000025787.V310860.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. There is a system in place for the effective handling of complaints and service users and their relatives are encouraged to raise any concerns they have. Service users therefore know that their concerns will be acted upon. Suitable arrangements are in place for handling allegations and instances of abuse however, there was one instance of poor practice that did not ensure that service users would be protected from harm. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The Commission received an anonymous concern in July 2006, which alleged that one service user had not been supported to eat by staff members. Another anonymous concern about staff members “in general” failing to support service users to eat was raised with The Commission in May 2006. These issues were investigated by the home’s Responsible individual and found to be unsubstantiated. The home’s complaint log detailed that a complaint had been made directly to the home in June 2006. There were records detailing that this complaint had been handled appropriately and in a timely fashion. Service users spoken with were aware of how to make a complaint in the home. One service user said, “I’ve never needed to make a complaint” The home has a copy of Croydon Council’s vulnerable adult protection procedures. Records were available detailing that staff members have undergone training in the Protection of vulnerable adults. Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 18 It is of concern that the writer, on arrival at the home, was welcomed in by a staff member, without their identification being checked, then left alone in the hallway for approximately seven minutes. Staff members must be more vigilant about allowing people into the home in order to ensure that the well being of service users is protected. A Requirement is made in relation to this issue. Hall Grange DS0000025787.V310860.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 and 26. The home is not ideally suited to the needs of service users, however, it is maintained, decorated and furnished to an adequate standard and facilities are clean. This ensures that service users live in a pleasant and homely environment. There is a need for a number of environmental improvements to ensure that comfort, health and safety is maintained. Quality in this area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home is well maintained and good efforts have been made by the staff team to create a pleasant and homely environment for those who live there. It is positive that the Manager has advised that she is in the process of planning for a number of environmental improvements in the home such as redecoration and refurbishment in some areas. Three service users spoke of Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 20 their disappointment during this inspection about the unsuccessful bid for planning permission, regarding the repositioning of the home to a site next door. One service user said “we would have much better facilities if we moved” Generally, service users spoken with said that they were happy with the environment. Bedrooms seen were small, but had been made homely. Each bedroom had an en suite facility, which was also small, and potentially difficult to manoeuvre in. The suitability of the en suite facilities, for service users who have needs that change must be closely monitored by the home. Likewise, some communal bathrooms and toilets were small and service users with increased needs my find these difficult to use. It is disappointing that two Requirements made at the last inspection of the home regarding the physical environment, and better outcomes for service users have not been met within agreed timescales. There remains a need for staff training in sensory impairment and for the premises to be risk assessed in relation to the hazards associated with visual impairment. It is acknowledged however, that this training has been arranged following consultation with the Royal National Institute for the Blind. All senior staff members are scheduled to undertake training regarding visual impairment. The Manager said that this would then be cascaded to all other staff members and risk assessments of the home will be carried out following the training. There are storage facilities for wheelchairs and other pieces of disability equipment. It was therefore disappointing to note that a wheelchair and a Zimmer frame were stored in a corridor at the time of this inspection, preventing the use of the handrail. A Requirement is made regarding this issue. All areas of the home viewed were noted to be clean and the majority of areas were free from offensive odours. One bedroom smelt unpleasant. A staff member said that this bedroom’s carpet was scheduled to be steam cleaned on the day of this inspection. Cleaning staff members were on duty during this inspection and service users spoken with said that they found the home to be well cleaned. Laundry facilities are suitable. There are policies and procedures for the control of infection; however, some cleaning products were stored under the sink in the communal lounge. All cleaning products must be stored in a locked facility when not in use. A Requirement is made regarding this issue. Hall Grange DS0000025787.V310860.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staff members are provided in adequate numbers; however, the procedures for the recruitment of staff members and volunteers are not robust and do not provide the safeguards to offer protection to people living in the home. There have been some improvements with the staff training and development programme, however, there remains a need for some training in order to fully meet the needs of service users. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The number of care staff members in the home at the time of this inspection, and detailed in staffing rotas appears to be adequate, and in line with the needs of the current service user group. A large number of volunteers work in the home. Four relatives surveyed said that they believed that there are sufficient staff members on duty in the home. However, four service users said that there was not enough staff members, and that they, on occasion, had to wait too long when they needed assistance from a staff member. The Manager should give consideration to these comments, when reviewing the staffing levels, as intended. Improvements have been made in relation to NVQ Level 2 in Care training for staff members. A number of staff members now have, or are working towards Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 22 this qualification. Training in recognising, preventing and reporting elder abuse has occurred since the last inspection of the home. A Requirement made regarding this issue is now meet. There remains a need for staff training in sensory awareness. Criminal Records Bureau checks have been obtained for the majority of the volunteers working in the home. However, it is extremely concerning that there was no Criminal Records Bureau check for the most recently recruited volunteer, despite Requirements being made regarding this issue at the last two inspections of the home. An Immediate Requirement was issued at the time of this inspection regarding this and the Manager was reminded of her responsibility to protect the wellbeing of service users. A failure to obtain a Criminal Records Bureau checks for volunteers in the future will result in enforcement action being taken by The Commission. Three new staff members have been employed to work in the home since the last inspection. The majority of the necessary pre recruitment checks had been carried out, and relevant documentation obtained, prior to these staff members commencing work. However, there was no photographic identification available for these staff members. Also, there was only one written reference in place for one staff member. The reference had been obtained from the staff member’s friend. Written references should be obtained, where possible, from previous employers. A Requirement is made regarding these issues. Hall Grange DS0000025787.V310860.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. There has been an improvement in relation to the management of the home, which has resulted in improved outcomes for service users and there is generally, a good quality assurance system however, some improvements to the quality assurance system are required to ensure that the home is run in the best interests of service users, In general, there are adequate arrangements for ensuring health and safety. However, there remain some concerns regarding health and safety in the home, which potentially places the wellbeing of service users at risk. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home has been without a Registered Manager for a number of months and managerial responsibility has been shared between the senior staff team. It is Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 24 of concern that a high number of Requirements set at the last inspection of the home have not been met in the absence of a Registered Manager. However, it is positive that a new, experienced manager has been recruited. The Manager presented as being confident, competent and professional throughout this inspection. The Manager stated her intentions to make an application to become registered with the Commission for Social Care Inspection. This must be done in order for this Standard to be met. There are a number of tools for self- monitoring. Service users and their family members are surveyed on a regular basis about their views on the home. One service user said that they were provided with opportunities for giving feedback both formally, and informally. Another service user said that they felt listened to by staff at the home, and confident that any concerns would be dealt with appropriately. There has recently been an in-house audit, known as a ‘Standards and Values Assessment’ Detailed information has been gathered regarding outcomes for service users in the home. Both positive and negative outcomes have been identified and the Manager said that work is to be carried out to make improvements in the home following the audit. This is good practise. Progress with this will be examined at the last inspection of the home. There was documentation detailing that there are plans to carry our regular medication audits. This is seen as important and a timescale for carrying out such audits is detailed in the Requirement section of this report. It was positive to note that the management team were meeting at the time of this inspection to review the home’s record keeping, with a view to improvement. There were minutes detailing that there have been two senior team staff meetings throughout the year. There were no records regarding team meetings for the wider staff team. It is necessary that staff meetings are held on a regular basis, with records kept, as discussed during the previous inspection of the home. More positively, one service user said that they had been asked to draw up a questionnaire regarding food served in the home, which would them be distributed to service users. Family members, in general, retain control over service user’s finances. Money is kept in the home’s safe for some service users. The Manager confirmed that receipts are provided for all transactions. Records were not examined during this inspection regarding the money held by the home on behalf of service users. However, previous inspections of the home have found records to be in good order. The faulty sound activated release mechanism attached to the fire door at the tip of the main stairs has been removed and the Manager stressed that this door remains closed at all times. A Requirement regarding this issue is now meet. All bedroom doors have an activated release mechanism and there were records detailing that these are safety checked on a regular basis. However, it is concerning that the doors to the office, and to the salon, were wedged open Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 25 at the time of this inspection. A repeat Requirement is made regarding this issue and a failure to comply with this may result in enforcement action. The Commission has not received reports of the home’s Regulation 26 visits. These visits must occur and reports must be sent to The Commission, as discussed at the last inspection of the home. Staff members are trained in safe working practices such as moving and handling, food hygiene, infection control and first aid. Records indicated that there are regular safety checks on food, fridge and freezer temperatures, however, records available detailed that there had been a failure to records fridge and freezer temperatures during the last two weeks. A Requirement is made regarding this. Checks occur on the fire alarm, fire fighting equipment, and door guards. There are regular fire drills, boiler safety checks, gas and electricity safety checks, portable electrical appliance safety checks and testing for legionella. Regular safety checks of hoists, baths and the lift occur. There are risk assessments in place for chemicals and all accidents and incidents are recorded. There were no records available detailing that the emergency lighting is safety checked. Safety checks must occur, with records kept. Hall Grange DS0000025787.V310860.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 3 X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 2 X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X 3 X 2 2 Hall Grange DS0000025787.V310860.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 OP1 Regulation 4(1)(c), Sch 1.6 Requirement Timescale for action 01/12/06 2. OP7 15 (1)(2)(b) 3. OP9 13 (2) 4. OP9 13 (2) The Registered Provider must ensure that more specific information about the range of needs that the care home intends to meet must be included in its Statement of purpose/service users guide. Repeat Requirement. Timescale of 01/04/06 unmet. The Registered Provider must 01/12/06 ensure that each service user has a care plan that clearly details how all of their personal, health and social care needs will be met. The Registered Provider must 01/11/06 ensure that Medication Administration Records are kept up to date and accurate. The Registered Provider must 15/10/06 ensure that all medication prescribed to service users by their General Practitioner, is administered. (Were a service user refuses this medication over a significant period of time there must be consultation with the General Practitioner regarding DS0000025787.V310860.R01.S.doc Version 5.2 Hall Grange Page 28 5. OP9 13 (2) 6. OP18 12 (1)(a) 7. OP22 12 (4) 23 (2)(n) 13 (4) this) The Registered Provider must ensure that there are regular audits of the medication in the home, with records kept. The Registered Provider must ensure that staff members are clear about the home’s policy on welcoming visitors into the home. (i.e. checking identification documentation and accompanying them to the desired location) The Registered Provider must ensure that advice be sought from the Royal National Institute for the Blind (RNIB) and/or other relevant bodies about specialist aids; equipment and adaptations that could be used to improve the lives of the homes visually impaired service users. Furthermore, risk assessments of the premises that specifically focus on the hazards associated with visual impairment must be undertaken. Repeat Requirement. Timescale of 01/06/06 unmet. The Registered Provider must ensure that sufficient numbers of staff attend sensory awareness training to meet the needs of all the homes visually impaired service users. Documentary evidence of this training must be made available for inspection on request. Repeat Requirement. Timescale of 01/06/06 unmet. The Registered Provider must ensure that wheelchairs, and other pieces of disability equipment are not stored in corridors. DS0000025787.V310860.R01.S.doc 01/11/06 01/11/06 01/12/06 8. OP22 18 (1) Sch 2.4 01/12/06 9. OP22 13 (4)(c) 23 (2)(l) 01/11/06 Hall Grange Version 5.2 Page 29 10. OP26 12 (1)(a) 11. OP29 19 (1)(a) Sch 2 (7)(a) The Registered Provider must ensure that cleaning products are stored in a locked facility when not in use. The Registered Provider must ensure that a satisfactory Criminal Records Bureau and Protection of Vulnerable Adult Protection checks is obtained in respect of all its voluntary workers. Up to date copies of these checks must be available for inspection on request. IMMEDIATE REQUIREMENT ISSUED Repeat Requirement. Timescales of 01/01/ 06 and 01/07/06 unmet. The Registered Provider must ensure that two satisfactory written references and photographic identification are obtained, prior to any staff member working in the home. These must be available for inspection. The Registered Provider must ensure that staff meetings are held at regular intervals and minuted. Repeat Requirement. Timescale of 01/03/06 unmet. The Registered Provider must ensure that The Commission is supplied with a copy of any report carried out in accordance with Regulation 26. Repeat Requirement. Timescale of 01/03/06 unmet. The Registered Provider must ensure that under no circumstances must fire resistant DS0000025787.V310860.R01.S.doc 01/11/06 29/09/06 12. OP29 19 (1)(a) Sch 1 & 5 01/10/06 13. OP32 18(1) 01/11/06 14. OP37 26(5) 01/11/06 15. OP38 23(4)(c) 01/11/06 Hall Grange Version 5.2 Page 30 17. OP38 12 (1)(a) 13 (3) 18. OP38 12 (1)(a) 13 (3) doors be wedged open. Repeat Requirement. Timescale of 20/02/06 unmet. The Registered Provider must ensure that fridge and freezer temperatures are monitored, with records kept, on a daily basis. The Registered Provider must ensure that there are regular safety checks on the emergency lighting, with records kept. 01/11/06 01/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hall Grange DS0000025787.V310860.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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