Inspection on 07/02/06 for Hall Grange

This inspection was carried out on 7th February 2006.

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 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 27/09/06

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 Lee Willis Unannounced Inspection 7th February 2006 12:15 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.V274229.R01.S.doc Version 5.1 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.V274229.R01.S.doc Version 5.1 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.V274229.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2005 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. Marion Evans is no longer the registered manager of the service, having resigned her post in December 2005. In the interim, the homes three assistant managers, who are also being supported by other senior managers within MHA, will remain in operational day-to-day control of Hall Grange. There have been no changes made to the homes physical environment since its last inspection, although the Commission is aware that plans are still being drawn up 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 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. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 12.15 on the morning of Tuesday the 7th February 2006. It was carried out over five hours and as it did not finish until just after 5pm the Commission considers it to be a partially out of hours visit. Since the homes last inspection, which took place in October 2005, the Commission has not received any more comment cards in respect of this service. The majority of this inspection was spent talking to the homes new temporary acting manager, six service users, two family members who were visiting their loved one at the time, and numerous members of staff, including; several care workers, caterers and a business support worker. Out of the half or dozen or so service users met, only two were spoken with at length. The remainder of this inspection 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: What has improved since the last inspection? Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 6 The home has managed to meet the vast majority of requirements identified in its last inspection report within the prescribed timescales for action. Important areas of practice that have improved since its last inspection, includes: Amendments made to its Statement of purpose and guide, which now contain up to copies of the providers complaints procedures, thus ensuring all the relevant stakeholders know how to raise any concerns they may have about the homes operation. Furthermore, appropriate records are now being maintained of all the complaints made about the home, which includes more detailed information about all the action taken by the registered providers in response to concerns raised. The home has also managed to convert most of the service users care plans into more person centred formats that set out in greater detail each individuals personal preferences, strengths and aspirations, although the acting manager acknowledges that there is still some way to go for this task to be complete. Finally, a new activities coordinator has been employed to ensure the service users have more opportunities to engage in stimulating social, religious and recreational activities of their choice. The home has also made some progress to improve the lives of its visually impaired service users by arranged for the Royal National Institute for the Blind to carry out an assessment of the building and for staff to receive visual impairment awareness training. What they could do better: The positive comments made above notwithstanding their remains a number of key areas of practice the home needs to improve upon: Firstly, although all three of the homes assistance managers have done well to keep the home running ‘smoothly’ in the absence of a registered manager, it was disappointing to note that records revealed that no staff meetings had taken place since November 2005 and nor had the outcomes of all the fire drills undertaken by staff in the past twelve months been recorded. Secondly, although the registered providers have a relatively good track record of working in partnership with other agencies it was nevertheless disappointing to discover during the course of this inspection that the homes registered manager had resigned almost two months before. The providers failed to notify the Commission about this significant event as soon as reasonably practicable, and more importantly about the arrangements they proposed to put in place in the interim, contrary to the Care Homes Regulations (2001). The home also needs to ensure copies of all the unannounced inspection reports carried out by senior representatives of MHA are forwarded to the CSCI. Thirdly, there still have been no changes made or plans agreed to alter the interior design and layout of the building, which does not to lend itself well to Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 7 the concept of ‘homeliness’. However, the Commission acknowledges that MHA have continually experienced problems getting planning permission approved to rebuild the home on the same site. Finally, only limited progress has been made by the home to obtain satisfactory Criminal Records Bureau and Protection Of Vulnerable Adult register checks in respect of all its voluntary workers, despite this being identified as a major shortfall in the homes previous inspection reports. The safety of the service users must be paramount and MHA are reminded that they have a duty of care to ensure that all the people they employ are ‘fit’ to work with vulnerable adults. 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.V274229.R01.S.doc Version 5.1 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.V274229.R01.S.doc Version 5.1 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 Significant progress has been made by the home to improve its Statement of purpose/guide to ensure prospective new service users and their representatives are provided with all the information they need to make an informed decision about whether or not to move into Hall Grange, although more details about the range of needs the home caters for should also be included. 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, and as required in the last inspection report the homes arrangements for dealing with complaints has now been included. Having discussed the contents of this document with the homes most senior assistant manager it was agreed that more detailed information about the range of needs Hall Grange intends to meet should be contained in its Statement of purpose. It was positively noted that both the homes Statement and guide had been reviewed in the past six months and updated accordingly to reflect all the changes that had occurred in that time. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 10 Furthermore, an audio version of the guide was also available for the homes visually impaired service users. The home does not offer intermediate care e.g., short term intensive rehabilitation. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 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 & 9 The home has suitable arrangements in place to ensure service users individual personal, social and health care needs are planned for and met. Furthermore, the homes arrangements for handling medication are sufficiently robust to minimise the risk of service users being abused or harmed. EVIDENCE: The acting manager said the homes new care plan format, which is far more person centred and contains more detailed information about the support each service user requires, is used for all new admissions. However, the process of converting all the existing service users care plans into the new format was still on going. Progress on this matter will be assessed at the homes next inspection. Incident sheets sampled at the home random revealed that service users health continues to be closely monitored by staff and that the home continues to keep detailed records of all falls involving service users, as well as near misses. Commission continues to be notified with out delay about any such incidents involving service users in accordance with the Care Homes Regulations (2001). This information regarding falls was recently used to great Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 12 effect by the home to ensure one service user in particular was appropriately moved on to a far more ‘suitable’ placement where staffing ratios were more suited to meet this individuals changing physical needs. The homes accident book reveals that the aforementioned service user was admitted to hospital on two separate occasions in the same day having fallen over and seriously injured themselves twice in this time. Medication administration records sampled at random accurately reflected the medicines held by the home on service users behalves. Staff meticulously maintained these records. In addition, each service user has a personal medicines profile, which sets out in detail their current medication regime. The home handles Controlled drugs prescribed to service users. These are stored in a locked metal cupboard within the homes medicines cabinet, which is securely fixed to a wall in the office. Furthermore, ‘suitably’ qualified staff appropriately maintain a separate Controlled drugs register that clearly identifies a running total of all the Controlled drugs handled in the home, which two staff always sign for. 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. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 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, 14 & 15 The home ensures service users every opportunity to pursue their social, religious and recreational interests, both at home and in the wider community. These opportunities are well managed, ‘age’ appropriate, and provide the service users with daily variety and stimulation. Service users are offered a wide variety of nutritionally well-balanced and appealing food ensuring their dietary needs and preferences are well catered for. EVIDENCE: Two service users spoken with while on a brief tour of the premises said they were generally satisfied with the opportunities they had to pursue their social, religious and recreational interests. One service user said they particularly enjoyed the art classes. It was positively noted that since the homes last inspection, a new activities coordinator has been employed. All the activities on offer that day were conspicuously displayed on notice boards in the main entrance hall and near the first floor dinning area. The two service users met both said a beautician had visited the home that morning as advertised on these boards. A Methodist Minister continues to hold services on a regular basis in the ground floor lounge for anyone who chooses to attend. The assistant manager said as recommended in the homes previous inspection report she would talk to the local mobile library service about the possibly of Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 14 getting more large print and audio books for the homes visually impaired service users. A service user who was met while walking in the grounds with members of their family their said despite numerous requests the home had failed to provide her with a front door key. This matter was raised with the acting manager at the time of the this inspection who said service users are entitled to have keys to the home if they wish and promised this issue up. The aforementioned service user and two members of their family met said; overall they were generally satisfied with the standard of care being provided at Hall Grange. The overwhelming response of service users and their guests spoken with on the day of this inspection about the quality of meals served was extremely positive. Several service users met said the meals were always varied and very tasty, and all in all it was probably the ‘best’ thing about living at the home. The three choices of lunchtime meal of braised lamb chops, bacon pie and mixed bean casserole, were all accompanied with a choice creamed potatoes and cauliflower, which service users could help themselves too. Having walked passed the dinning room while lunch was being served all the meals looked and smelt extremely appetising. Service users met said there is always a vegetarian option on the menu. The atmosphere in the dinning room over lunch also looked and felt extremely relaxed and unhurried. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 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 The arrangements the home has in place for dealing with complaints ensures service users and their representatives concerns will always be taken seriously and acted upon. The homes vulnerable adult protection and abuse prevention measures are also suitably robust to ensure the service users are, so far as reasonable practicable, protected from avoidable harm. EVIDENCE: All the service users and relatives met during this inspection said on the whole staff were very approachable and always took account of their point of view. The homes complaints log, and separate concerns and suggestions book, both revealed that no formal complaints or informal concerns have been made about the homes operation since it was last inspected in October 2005. Furthermore, no disclosures of alleged or suspected abuse have been made within the home during this same period. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 16 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 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. Some progress has been made to meet the needs of the homes visually impaired service users although more needs to be done to ensure these particular group of individuals independence is maximised. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 17 EVIDENCE: The home is generally suited for its stated purpose, although as the acting manager and many of the service users and their relatives all acknowledge, the interior design of the building has never lent itself well to the concept of ‘homeliness’. The manager believes recently revised plans to rebuild the home on the same site have been rejected by the Local Authority for a second time and is uncertain what the providers are proposing to do next. The acting manager has agreed to keep the Commission informed about any developments and this matter will continue to be assessed at inspections. As previously mentioned, the home is located in a beautiful conservation area, which one service user and their family were making good use of at the time of this inspection. The home currently caters for three service users who are registered blind with varying levels of sight. As highlighted in the homes previous inspection reports concerns have been raised about the ‘suitability’ of the premises and the competence of staff to meet the specific needs of the homes visually impaired service users. As mentioned in the homes previous report the acting manager, who is now in temporary day-to-day control of the home, was extremely receptive at the time about looking into new ways to meet the needs of this particular group of service users. Consequently, she has recently made contact with the Royal National Institute for the Blind (RNIB) to seek their advice on this matter. The manager said the RNIB have now agreed to visit the home and assess the premises. Furthermore, the acting manager has also put in a request to her line manager for her staff team to receive sensory impairment awareness training. As some progress has been made to address this issue the requirements identified in the homes previous inspection report pertaining to this matter will not be considered unmet. These requirements will therefore merely be repeated in this report and the previous timescales for action extended. Progress to meet this on going issue will be closely monitored during the course of the next inspection cycle, commencing 1st April 2006. The temperature of water running from a hot tap attached to a first floor bath nearest the oldest part of the building was found to be a safe 41 degrees Celsius at 13.20. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 18 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 & 30 Overall, the home ensures that sufficient numbers of suitably competent and qualified staff are on duty at all times to meet the health and welfare needs of the service users, although the temporary acting manager concedes more staff need to receive recognising, preventing and reporting elder abuse training. Furthermore, although the homes recruitment procedures are in the main sufficiently robust to minimise the risk of service users being harmed by individuals who are ‘unfit’ to work with vulnerable adults, the process of checking all the homes existing voluntary work force against the Criminal Records Bureau (CRB) and Protection Of Vulnerable Adults (POVA) register, needs to be completed as a matter of urgency. EVIDENCE: On arrival it was noted that the number of staff on duty at the time was sufficient to meet the needs of the service users, which included: the acting manager, three care workers, three domestics, two caterers, an activities coordinator, and a business support worker. During a tour of the premises it was positively noted that all the members of staff who had just come on duty to work the late shift were receiving a thorough handover from a member of staff who had just worked an early. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 19 The acting manager stated that approximately two thirds of the homes care staff had either already achieved a National Vocational Qualification in care level 2 or above or were currently enrolled on a suitable course. The home has almost ensured that 50 of its current care team are NVQ trained and are well on course to exceed this target by the middle of 2006. Progress on this matter will be assessed at the homes next inspection. The home continues to experience relatively low levels of staff turnover and consequently only two new permanent members of staff have been employed since October 2005, including one senior carer and an activities coordinator. Both these new member of staffs’ file was examined in some depth and found to contain all the information required by the Care Homes Regulations (2001), including proof of their identity; 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. Both these members of staff were not permitted to commence their employment at the home until a satisfactory Criminal Records Bureau (CRB) check had been completed, in accordance with good recruitment practices. The home continues to employ around 70 volunteers who are all members of the local Methodist community. The acting manager said none of these volunteers are permitted to undertake tasks that are the responsibility of paid staff or work unsupervised with the service users. Furthermore, the manager went on to say that all new volunteers are subject to the same vigorous recruitment procedures as paid staff. This practice was confirmed by the relative of one service user who said they had recently applied to work at the home as a volunteer and had been required to supply MHA with an up to date CRB. However, only limited progress has been made by MHA to obtain CRB’s in respect of all its existing volunteers, many of whom have worked at the home for sometime. MHA have a duty of care to ensure all persons working at the home are ‘fit’ to work with vulnerable adults and must make more of a concerted effort to obtain up to date CRB and POVA checks for all its existing volunteers. This requirement is consider unmet and the timescale for action will be extended for a second time. Staff records sampled at random revealed that they were all suitably qualified to carry out their duties and had recently received accredited training in fire safety, moving and handling, basic food hygiene and first aid. The manager said arrangements are currently being made for staff to attend infection control training. Progress on this matter will be assessed at the homes next inspection. In the interim, the temporary acting manager acknowledges that the vast majority of her current staff team need to up date their existing knowledge and skills with regard recognising, preventing and reporting elder abuse. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 20 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, 32, 33, 35, 37 & 38 The homes health and safety arrangements are in the main sufficiently robust to ensure service users are, so far as reasonably practicably, protected from avoidable harm. However, fire safety arrangements need to be improved so that all the fire drills undertaken by staff are recorded and the practice of wedging fire resistant doors open ceases immediately. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 21 EVIDENCE: The homes most senior assistant manager, Nightingale Bikobbo, has been in temporary day-to-day control of Hall Grange since the homes former manager, Marion Evans, resigned in December 2005. Nightingale has a wealth of experience of working with older people in a residential care setting and is in the process of studying for her NVQ Level 4 Registered Managers Award, which she hopes to have completed by April 2006. The Commission recently received written confirmation from MHA that Marion Evans had ceased to manage the care home. The letter also outlined what arrangements MHA had put in place to manage the home on a day-to-day basis until such time as a new manager was appointed. The Commission is satisfied with the interim arrangements the providers have put place, although it was nevertheless disappointing to discover this change during the course of this unannounced inspection, at least two months after the homes former manager had resigned. Comments made by service users, their relatives and staff confirmed that as a direct result of the recent changes the homes formal arrangements for consulting service users and staff about the homes operation had been adversely affected. For instance, records revealed that no staff or service users meetings had been held in the home, or at least minuted, since October 2005. The home has a good track of formally consulting staff and service users about the homes operation and these good practice systems should be reinstated as soon as practicable. Staff meetings should be held at least six times a year. These comments notwithstanding two service users met said the providers remained very good at ascertaining their views through the use of satisfaction questionnaires. A recent quality assurance survey was undertaken by MHA in January 2006 and the acting manager is confident these results will be published soon. Progress on this matter will be assessed at the homes next inspection. Approximately a third of the service users currently residing at the home receive a degree of support from staff to help them manage their finances. It was positively noted that all the money held by the home on service users behalves is securely stored in the safe in individually marked wallets. The balance recorded on the three financial transactions sheets sampled at random all matched the amounts held in the homes safe on their behalves. No recording errors were visible on the records sampled. The homes last unannounced inspection undertaken by a senior representative of the registered providers was carried out in January 2006 and a report written about the findings of the visit, in accordance with the Care Homes Regulations (2001). The temporary acting manager was unaware that copies of these so-called Regulation 26 reports must be forwarded to the Commission and has agreed to rectify the shortfall. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 22 The homes fire records revealed that fire alarm tests continue to be carried out on a weekly basis and the manager said fire drills are undertaken on a quarterly basis. However, the homes fire drill record showed that although the last drill was carried out in January 2006, it only contained one entry for 2005. Fire extinguishers checked at random were all tested in October 2005. It was concerning to note that a fire resistant door at the top of the main stair case on the first floor was being wedged open, contrary to fire safety guidelines. The faulty sound activated release mechanism, which normally keeps this fire door propped open, needs to be repaired/replaced as a matter of urgency. The manager is reminded that under no circumstances must fire resistant doors be wedged open restricting their automatic closure in the event of a fire. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 23 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X 3 X 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 1 Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 24 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 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. 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 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. DS0000025787.V274229.R01.S.doc Timescale for action 01/04/06 2. OP22 12.4 23.2(n) 13.4 01/06/06 3. OP22 18(1), Sch 2.4 01/06/06 Hall Grange Version 5.1 Page 25 4. OP29 19, Sch 2.7 5. OP30 13(6) & 18(1) The home must obtain satisfactory Criminal Records Bureau and Protection of Vulnerable Adult Protection checks in respect of all its voluntary workers. Up to date copies of these checks must be available for inspection on request. Previous timescale for action of 1st January 2006 not met. Sufficient numbers of the homes current staff team must receive suitable training in recognising, preventing and reporting elder abuse. The registered person must notify the Commission as soon as it is practicable to do so if a person ceases to carry on managing a home. Staff meetings must be held at regular intervals and minuted. The Commission must be supplied with a copy of any report the registered persons are required to carry out in accordance with Regulation 26. Under no circumstances must fire resistant doors be wedged open. The faulty sound activated release mechanism attached to the fire door at the tip of the main stairs must be repaired as a matter of urgency. A record of every fire practice/drill conducted in the care home must be appropriately maintained and made available for inspection on request. 01/07/06 01/06/06 6. OP31 39(b) 01/03/06 7. 8. OP32 OP37 18(1) 26(5) 01/03/06 01/03/06 9. OP38 23(4)(c) 20/02/06 10. OP38 17(2), Sch 4.17 01/03/06 Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 Page 26 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. 3. Refer to Standard OP12 OP28 OP32 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 an NVQ level 2 or above in care. Service users should be consulted about the homes operation and have the opportunity to attend residents meetings at regular intervals, which should be minuted. Hall Grange DS0000025787.V274229.R01.S.doc Version 5.1 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. 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