Inspection on 28/10/05 for Hall Grange

This inspection was carried out on 28th October 2005.

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

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

Other inspections for this house

Hall Grange 31/07/07

Hall Grange 27/09/06

Hall Grange 07/02/06

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 Lee Willis Unannounced Inspection 10:30 28 October 2005 th 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.V254800.R01.S.doc Version 5.0 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.V254800.R01.S.doc Version 5.0 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) Methodist Homes for the Aged Mrs Marion Evans Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2005 Brief Description of the Service: Hall Grange is owned by the ‘Methodist Homes for the Aged’ 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. There have been no changes made to the homes physical environment since the last inspection, although the Commission is aware that the registered providers have recently submitted plans to the local Authority to rebuild the home on the same site. 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 which has 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 for service users and their guests to prepare their own snacks and drinks; a separate room used solely for hairdressing; and numerous communal meeting areas. 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. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 10.30 on the morning of Friday 28th October 2005 and took three and three quarter hours to complete. Since April 2005, the start of the new twelve-month inspection cycle, the Commission has received thirty-three comment cards in respect of this service, which is a very good rate of return for a home of this size. Twenty-two were returned by the service users, nine by their relatives, and the rest by volunteers who work at the home on a regular basis. The majority of this inspection was spent talking to three of the residents and one of the homes assistant managers at length; other members of staff on duty at the time, including a relief cook, a care worker, laundry assistant and a volunteer; and one of the homes immediate neighbours. The rest of the time was spent examining the homes records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months. What the service does well: All the service users met said overall they were satisfied with the standard of care they were receiving at Hall Grange. Furthermore, the overwhelming majority of the comment cards returned were also extremely positive about the home. One service user wrote, “Its very nice at Hall Grange, I am happy here. Every one knows me and I would not like to live anywhere else”. All the service users met agreed that the quality and choice of the meals provided was something the home did particularly well. Furthermore, it was positively noted that lots of detailed information about the choice of meals on offer, as well as the social, religious and recreational opportunities provided, was conspicuously displayed on notice boards throughout the home. A lot of positive comments were also received from service users about the homes commitment to meeting spiritual needs. At the time of arrival a dozen or so service users and some voluntary workers had begun gathering in the main lounge to listen to a morning service that was going to be conducted by a local Methodist Minister. All the staff on duty at the time of this unannounced inspection, which included domestic, catering, and voluntary workers, were all observed interacting with the service users in a very friendly and respectful manner. An unpaid member of staff wrote on a comment card, “ I have worked at the home as a volunteer for 12 years and have always been impressed with the staff, who are all very caring.” Furthermore, the home continues to enjoy the benefits of having a relatively stable staff team, which has changed very little in the past six Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 6 months, ensuring the service users are supported by individuals who are familiar with their unique needs, feelings and preferences. What has improved since the last inspection? What they could do better: These positive comments made overleaf notwithstanding, there are some areas of practice the home could and should improve upon: Firstly, the homes complaints procedure needs to be made more accessible, especially for new admissions, and copies should be included in the service users guide. In addition, all concerns and formal complaints made about the homes operation should be kept in a single source document for ease of referencing purposes, which should include the nature of the complaint, the outcome of the subsequent investigation, and action taken (if any) in response. Secondly, the interior design and layout of the building does not particularly lend itself well to the concept of ‘homeliness’, although as previously mentioned, new plans to rebuild the home from scratch are being considered by the Local Councils Planning Department. A decision is expected early next year. Finally, concerns were raised by some of the homes visually impaired residents and their relatives that not enough was currently being done by the home to meet the specific sensory needs of these individuals. One service user wrote, “I do think that the carers have been trained in care for sight impairment which leaves me feeling very insecure.” Having discussed these matters with the assistant manager on duty at the time it was agreed that the Royal National Institute for the Blind (RNIB) should be contacted and advice sought about specialist adaptations, equipment and aids, that could be used to improve the lives of the homes increasing number of visually impaired service users. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 7 Furthermore, sufficient numbers of the current staff should attend visual impairment awareness training. 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.V254800.R01.S.doc Version 5.0 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.V254800.R01.S.doc Version 5.0 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, 5 & 6 Prospective service users and their representatives are supplied with the vast majority of information they need to make an informed decision about whether or not to move in, although a copy of the homes complaints procedures must also be included in its statement of purpose/guide to enable service users and their relatives to feel confident that any complaints or concerns they may have will be listened to, taken seriously and acted upon. Suitable arrangements are in place to ensure no service user moves into the home without having their needs thoroughly assessed. EVIDENCE: The homes Statement of purpose/guide contains the vast majority of information service users and their representatives need to know about the services and facilities Hall Grange has to offer. However, having read this document with one of the homes most recent admissions it was noted that it did no contain any information about the homes complaints procedures. This matter was raised with one of the homes assistant manager who acknowledged the oversight and agreed to amend the services users guide to include a summary of the homes complaints procedures. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 10 This point notwithstanding it was noted that a copy of the homes complaints procedure was conspicuously displayed on a notice board in the entrance hall. The assistant manager said the home had received eight new referrals since February 2005. Copies of needs assessments undertaken by the homes manager were available on request in respect of these individuals. Two assessments sampled at random contained lots of detailed information about the prospective new service users and covered most aspects of their personal, social and health care needs. One of the homes most recent admissions, who was spoken to at length, said they had been invited to come and visit the home before moving in, but because of the distances involved had declined the offer. The home does not offer intermediate care e.g., short term intensive rehabilitation. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10 Suitable arrangements are in place to ensure service users individual personal, social and health care needs, including both physical and emotional needs, are being planned for and in met. Staff treats the service users with respect and their right to privacy is upheld. EVIDENCE: Two care plans sampled at random had recently been updated and the format improved to make it more person centred. These plans contained far more detailed information about the individual support each service user required to meet their unique needs. One service user met said they had been consulted about their new care plan and very much involved in drawing it up. The assistant manager said the process of converting all the existing service users care plans into the new format was almost complete. Progress on this matter will be assessed at the homes next inspection. Records sampled at random showed that service users health continues to be closely monitored by staff and other health care professionals, including GP’s, dentists, opticians, and chiropodists, who are all in regular contact with the home and able to check that individual service users healthcare needs are Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 12 being planned for and met. The home continues to keep detailed records of all falls involving service users, as well as near misses, and always notifies the Commission with out delay about any such incidents. The assistant manager said the home continues to analyse this information on a regular basis to determine whether or not any obvious patterns are emerging and to develop risk management strategies accordingly, in order to minimise the likelihood of similar incidents reoccurring in there future. This analytical tool has proven very successful in the past at reducing the number of falls in the home. There have been no unplanned admissions to accident and emergency since the homes last inspection. Having been invited by one service user to sit and talk with them in their room it was positively noted that a member of staff was heard knocking on the service users door and asking their permission to enter before doing so. This good practice was observed on numerous occasions during a brief tour of the premises. Two service users spoken to at length both felt staff treated them with respect at all times and were always kind and courteous. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 13 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 & 15 On the whole service users felt the lifestyle they experienced in the home matched their expectations and preferences, as well as satisfying their social, religious and recreational interests and needs. Dietary needs are well catered for, nutritionally balanced, and evidently based on service users personal preferences and wishes. EVIDENCE: Two service users spoken to at length said although there were plenty of organised activities and events for them to join in if they wished they preferred to spend most of their time relaxing in their own company. At the time of this inspection it was noted that a large number of service users had gathered in the main lounge for a morning service that was going to be conducted by a local Methodist Minister. The date and time of the service was conspicuously displayed on a notice board in the entrance hall for all to see. It was positively noted that a loop system had been installed in the main lounge to enable the service users with hearing impairments to follow the services. Several service users met very briefly in the main lounge said the services were an integral part of life at the home and as practising Christians meant their spiritual needs were well catered for. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 14 One service user who enjoyed reading said they were finding it increasingly difficult to do so because of their deteriorating eyesight. With the home catering for an increasing number of service users with visual impairments the assistant manager acknowledged that the service could do more to meet the specific needs of these individuals. It was therefore agreed that the home should consider buying and/or borrowing more talking and large print books. It was suggested that the local mobile library service, which visits the home on regular basis, would be a good place to start seeking advice on the matter. All the service users met said they were not aware of any restrictions on visiting times for their family and friends. The home employs lots of voluntary workers who are affiliated with the Methodist church. One volunteer, who was in the dinning room cleaning the kitchenette at the time, said they got a great deal of satisfaction from working at the home and felt valued by the service users. The assistant manager said all the service users have designated keyworkers. One of the homes most recent admissions said they were able to bring many of their possessions with them when they moved in, which included a wide variety of ornaments, pictures, and photographs, as well as some small items of furniture, such as a chair, coffee table and a small display cabinet. A number of service users were asked about the meals and everyone spoken to said they were extremely varied, tasty and plentiful. One of the homes most recent admission said there was always a vegetarian option on the menus. Having been on a tour of the kitchen it was positively noted that the ingredients being used by the relief cook was fresh and matched the published menu for the day, which was conspicuously displayed on the notice board in the entrance hall. The service users met were all aware that they had a choice between cod (poached or fried), or omelette, for their lunchtime meal. One service user said if they did not fancy any of the options on the published menus on a particular day they could always ask the cook to rustle up something else providing the ingredients were available. The relief cook said the catering staff always try their best to be as flexible as possible and accommodate service users food and drink preferences. It was positively noted that around 11am a member of staff came around knocking on service bedrooms to see if anyone who was in would like a hot drink and biscuits. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 15 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 & 18 On the whole service users are confident that any concerns and/or formal complaints they have will be listened to, taken seriously and acted upon. However, details about the nature of complaints, the subsequent investigations, and action taken in response must be kept in a single source document for ease of referencing purposes. The homes vulnerable adult protection and abuse prevention measures are suitably robust to ensure the service users are, so far as reasonable practicable, protected from avoidable harm. EVIDENCE: Several service users spoken to said staff were generally very approachable and willing to listen to any concerns they had. Records revealed that the home had received one formal complaint about it operation since February 2005. The relatives of a service user made the complaint and following an internal investigation on the matter it was successfully resolved to the complainant’s satisfaction. However, although detailed records were kept of the complaint this information should have been bound together in a single source document, detailing the nature of the complaint, the outcome of the subsequent investigation and the action taken (if any) in response. A procedure for responding to allegations or suspicion of abuse was available for inspection on request. The assistant manager said the home has never referred any members of its staff team for possible inclusion on the recently established Protection of Vulnerable Adults (POVA) register. The assistant manager was aware of her roles and responsibilities regarding vulnerable adult Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 16 protection and was very clear that all the relevant authorities must be notified without delay, including Croydon Social Services and the Commission, about any suspected, actual or alleged incidents of abuse that may occur within the home. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 17 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, 22, 25 & 26 The overall impression when visiting the home is that although the building is earmarked for redevelopment, it nevertheless remains a safe, hygienically clean and relatively comfortable environment for service users to live in. However, service users who are visually impaired need to be provided with more support, advice and specialist equipment/aids to enable them to maximise their independence. EVIDENCE: Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 18 The home continues to be suited for its stated purpose, although as the assistant manager and many of the service users met all acknowledge, the interior design of the building does not lend itself particularly well to the concept of ‘homeliness’. However, as previously mentioned, plans to rebuild the home have now been completed, although the assistant manager believes these were recently rejected by the Local Authorities Planning Department. Nevertheless, the assistance manager is confident that the service providers are in the process of drawing up some new plans, which can then be resubmitted to the Local Authority. Progress on this matter will be assessed at the homes next inspection. The home caters for four service users who are visually impaired to varying degrees. Having spoken to one service user who is visually impaired and the assistant manager about what arrangements the home has in place to meet the specific needs of its visually impaired residents, both agreed that more could and should be done. Furthermore, the relative of one service user wrote on a comment card about the home “overall the carers are not skilled at all in caring for someone who is blind: Lack of communication, therefore a feeling of isolation; unnecessary confusion as to where objects/food are. More training required.” Having discussed these matters with the assistant manager, who was extremely receptive to new ideas and good practice suggestions, it was agreed that in order to find out more about all the possible adaptations, specialist aids and equipment that could be used to improve the life’s of the homes visually impaired service users, it would be a good idea to consult the Royal National Institute for the Blind (RNIB). Examples of specialist adaptations and aids includes, additional and/or anti-glare lighting, colour contrasting, tactile symbols, varied textual surfaces, and padding hazards that cannot be removed. Secondly, a thorough risk assessment of the premises and individual service users needs, which specifically focus on the hazards associated with visual impairment, need to be undertaken by suitably qualified professionals as a matter of urgency. Finally, sufficient numbers of the staff should attend suitable training courses in visual impairment awareness. It was positively noted that a care worker responded to a call bell activated from a service users bedroom within four minutes of it being sounded. The assistant manager said staff are designated a certain number of service users at the beginning of each shift who they are ultimately responsible for, which includes responding to activated call bells as soon as reasonably practicable. Two service users met said staff were generally very good at responding to calls for assistance, and only very occasionally would an unacceptable delay occur. Having been on a brief tour of the homes laundry facilities it was positively noted that service users clean clothes had all been separated into individually labelled baskets by the homes permanent laundry assistant to minimise the risk of them being misplaced. One service user met said her clothes rarely go missing and when they do staff are quick to locate the missing item(s). Staff Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 19 preparing lunch in the kitchen were both appropriately attired with protective gloves and aprons, in accordance with basic food hygiene standards. The home was free of offensive smelling odours at the time of this visit and overall looked hygienically clean and tidy. Having tested the temperature of hot water emanating from two baths on the first floor they were both found to be a safe 42 degrees Celsius between 10.50 and 10.58am. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 20 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 Overall, the home ensures that sufficient numbers of suitably trained and competent staff are on duty at all times to meet the health and welfare needs of the service users. The homes recruitment procedures are in the main sufficiently robust to minimise the risk of service users being supported by individuals who are ‘unfit’ to work with vulnerable adults, although the task of ensuring all the homes existing voluntary workers are checked against the criminal record bureau needs to be completed. EVIDENCE: On a tour of the premises it was noted that five care staff, including one senior and the assistant manager, were all on duty at the time of this morning visit. Furthermore, two catering, three domestics, a laundry assistant, and at least two voluntary workers were also on duty at this time. Information about who was on duty that day was conspicuously displayed on a notice board in the entrance hall. Service users met said suitably competent staff were generally employed in sufficient numbers to meet their daily needs. The assistant manager stated that to the best of her knowledge approximately half the homes care staff team had either achieved or were working towards their National Vocational Qualification in care - level 2 or above. Consequently, the assistant manager is confident that the home is well on course to meeting National Minimum Standards for staff training by ensuring at least 50 of its carers hold an NVQ level 2 or above by the end of 2005. Progress on this matter will be assessed at the homes next inspection. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 21 The home continues to experience relatively low levels of staff turnover. Consequently, only one new recruit has been employed by the home since February 2005, although the assistant manager said she is currently in the process of shortlistng candidates for vacant care worker positions. The new member of staffs’ file was examined in some depth and found to contain proof of their identity, which included a recent photograph; two written references, one of which was from their last employer; and an up to date Enhanced Criminal Records (CRB) and Protection Of Vulnerable Adults (POVA) register checks. The home continues to employ around 50 volunteers who are all members of the local Methodist community. One voluntary worker spoken to briefly said they are not permitted to undertake tasks that are the responsibility of paid staff or work unsupervised with the service users. Furthermore, the assistant manager went on to say that all new volunteers are now subject to the same vigorous recruitment procedures as paid staff, but was unsure how many of the existing volunteer workforce had completed satisfactory Criminal Records check (CRB). This matter was discussed with the registered manager at the homes last inspection and it was agreed that this process would be complete by the end of 2005. Consequently, as the prescribed timescale for action had not expired at the time of this inspection this previously identified shortfall is not considered unmet, but on going, and is therefore merely repeated in this report with no change to the date for compliance. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 22 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): 38 Overall the homes health and safety arrangement, including those associated with fire safety, are adequate to protect the service users, their guests and staff from avoidable harm. However, arrangements for maintaining satisfactory standards of food hygiene in the care home need to be improved. EVIDENCE: Marion Evans continues to be the Registered manager of the home. At the time of the homes last inspection Marion was in the process of studying for her Registered Managers Award. As Marion was not on duty at the time of this inspection this standard was not assessed on this occasion. It was clear from conversations with service users and staff that Marion’s style of management continues to be a very open and inclusive one. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 23 Overall, the kitchen was clean and well equipped, although some condensed milk in its original aluminium packaging was found in a fridge. Kitchen staff removed the offending item immediately and they were reminded of the health risks associated with storing food in opened aluminium tins. The milk should have been transferred to a more suitable container, labelled and dated, in accordance with basic hygiene standards. A small annex off the kitchen that was full of fridges and freezers to store food at appropriate temperatures had a distinct smell of sour dairy products about it and also felt rather warm. It is appreciated that this room will eventually be replaced when the existing building is demolished, but in the interim it must be kept hygienically clean at all times, especially as the heat from the nearby boiler room tended to intensify the temperature in this small enclosed space. As required in the homes previous report the home invited the London Fire and Emergency Planning Authority (LFEPA) to inspect the homes fire safety arrangements on 9th May 2005. All three of the subsequent recommendations made by the fire brigade were met in full and in a timely fashion, including the undertaking of a fire risk assessment of the building, fire safety and exit notices made more visible and the removal of obstructions from fire resistant doors. Furthermore, up to date Certificate of worthiness were in place in respect of the homes fire alarm system and fire extinguishers, as proof suitably trained professionals had tested this equipment in the past twelve months. The assistant manager said fire exits are never obstructed or locked, which was confirmed during a tour of the premises. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 24 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X 2 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4(1)(c)Sc h1.14& 5(e) Requirement A summary of the homes complaints procedures established under Regulation 22 must be included in its Statement of purpose/service users guide. A record of all complaints made about the homes operation, including the nature of the complaint, the subsequent investigation, and the action taken (if any) in response, must be kept together in a bound single source document. Advice needs to 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. Sufficient numbers of staff must attend sensory awareness DS0000025787.V254800.R01.S.doc Timescale for action 01/12/05 2 OP16 17(2), Sch 4.11 01/12/05 3 OP22 12.4 23.2(n) 13.4 01/01/06 4 OP22 18(1) 01/02/06 Hall Grange Version 5.0 Page 26 5 OP29 6 OP38 training to meet the needs of all the homes visually impaired service users. 19, Sch All the homes voluntary workers 2.7 must have satisfactory criminal records checks. Up to date copies of these checks must be available for inspection on request. 13(4)&16( All food taken out of its original 2)(k) (j) packaging must be correctly labelled and dated and all areas where food is stored must be kept hygienically clean. 01/01/06 15/11/05 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 OP12 OP28 Good Practice Recommendations Talking and large print books should be made more widely available in the home for all service users to enjoy. 50 of all the carers working at the home should have obtained, or at least started, an NVQ level 2 or above in care course by the end of 2005. Hall Grange DS0000025787.V254800.R01.S.doc Version 5.0 Page 27 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.V254800.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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