Inspection on 13/09/07 for Holcroft Grange

This inspection was carried out on 13th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Holcroft Grange 02/06/06

Holcroft Grange 09/11/05

Holcroft Grange 19/04/05

Holcroft Grange 03/12/04

Holcroft Grange 17/08/04

Holcroft Grange 17/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Holcroft Grange Jackson Avenue Culcheth Warrington Cheshire WA3 4EJ Lead Inspector David Jones Unannounced Inspection 8.15 13 , 14 and 20 September 2007 th th 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 Holcroft Grange DS0000027011.V333284.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. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holcroft Grange Address Jackson Avenue Culcheth Warrington Cheshire WA3 4EJ 01925 766488 01925 766582 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) www.clsgroup.org.uk CLS Care Services Limited Pauline Shaw Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include: * up to 40 service users in the category of OP (old age not falling within any other category) may be accommodated. 2nd June 2006 Date of last inspection Brief Description of the Service: Holcroft Grange is a care home situated in the centre of the village of Culcheth. It is a single storey building. It offers accommodation, personal care and a wide range of facilities for up to forty older people. There are forty single bedrooms, three of which have en-suite facilities. There are three communal lounges and one dining room. A range of shops and other local facilities are within walking distance of the home and the village is supported by good public transport services. The home has good access for people in wheelchairs or with impaired mobility and there are pleasant garden areas for the people who live at the home to enjoy. Information about Holcroft Grange including copies of the most recent inspection report is made available to each resident and can be acquired by contacting the home on the telephone number given above. Fees range from £450 to £480 per week for accommodation, board and care, depending on the size of the room and whether additional facilities are provided such as en-suite’ toilet facilities. There are no additional charges other than hairdresser, toiletries, newspapers and other sundry items charged at cost. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection of Holcroft Grange was unannounced. It included a visit to the home, carried out over three days for a total of 13 hours and 50 minutes. The visit was just one part of the inspection. Before the visit, the manager of the home was asked to complete a questionnaire to provide CSCI with up to date information about the home. CSCI questionnaires were also made available for the people who live at the home, their families and health and social care professionals, including district nurses and their views have been taken into account. Other information received since the last key inspection was also reviewed. During the visit, various records were looked at and a tour of the home was carried out. Observations were made of how staff interacted with and provided care for the people who live at the home. A number of people who live at the home, visiting relatives and care staff were spoken with. They gave their views and these have been included in this report. What the service does well: Holcroft Grange is ideally located in the centre of Culcheth village so people who live at the home have good access to the local shops and other community facilities. The home provides comfortable and well-maintained accommodation and there is an attractive garden and inner courtyard that provides a safe area for people to sit and relax. People thinking of moving to the home have their needs assessed and are able to visit the home before they make decision so they know it is suitable for them. Care staff work in partnership with the person living at the home and their representatives including relatives and health and social care professionals to make sure that care is provided in a person centred way so residents’ needs are met in the way they prefer. The principles of privacy and dignity are promoted so people feel respected and valued. Care staff operate as an effective team. They are experienced, well trained and skilled so the people who live at the home know they are in safe hands and have confidence in the staff team’s abilities. Health care professionals work closely with the staff team to ensure that the health care needs of the people who live at the home are met. A district nurse Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 6 and a district nurse manager praised the staff team for their dedication and high standard of care provided. The home has effective complaints and adult safeguarding procedures, so vulnerable people are safe and protected from the potential for abuse. The people who live at the home and their representatives including relatives and health and social care professionals are asked about the quality of care, facilities and services provided. Their views are acted upon and published in the statement of purpose and service users guide so they know their views are taken seriously and the service benefits from a continuous cycle of consultation and improvement. What has improved since the last inspection? What they could do better: The management team must make sure that the home’s record and care planning systems are up to date so care staff have all the information they need to meet the needs of the people who live at the home and ensure their safety and well being. All people who are thinking of moving in to the home should be provided with a copy of the home’s statement of purpose and service users guide so they have Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 7 the information they need to make an informed decision about the home before they move in. Care plans should be drafted for all people within 48 hours of a moving in so staff have the information they need to meet the individual’s needs in the way they prefer. The “Kardex” system in the main kitchen should be kept up-to-date with the dietary needs and personal preferences of all the people who live at the home so all cooks including agency cooks have the information they need to meet each person’s dietary needs and respect their likes and dislikes. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Holcroft Grange DS0000027011.V333284.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 Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New people who are interested in moving to Holcroft Grange have their needs assessed and are usually given sufficient information about the care, facilities and services provided so they know how their needs will be met at the home. EVIDENCE: People who are thinking about moving in to Holcroft Grange are provided with a detailed brochure, which provides useful information about CLS including the philosophy of care and details about facilities and services provided at the home. They have their needs assessed and are able to visit the home so they can make an informed decision as to whether is suitable to meet their needs. When they move into the home they are given a detailed “Welcome Pack”. This provides a wealth of information about the home and facilities and services provided. It includes a statement of purpose and service users guide, the previous CSCI inspection report and details of the home’s quality surveys including the views and experiences of the people who live at the home. The information is provided in large print so people are able to read it easily. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 10 Most of people spoken with during the inspection said that they were satisfied with the information provided. However one person stated that they did not receive enough information about the home before moving in. The manager explained that the Welcome Pack is given to people once they have moved in. The brochure is detailed but it does not contain all the information that is provided in the service users guide. The service users guide should be given to all people before they move in so they have all the information they need to help them with their decision-making. Case records contain appropriate pre-admission assessment documentation and all people living at the home receive written confirmation from the manager that the home is suitable to meet their needs before they move in. All people living at the home are provided with a contract if they a privately funded or a statement of terms and conditions if they are supported by a local authority so they know their rights and responsibilities in relation to facilities and services provided. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that a person living at the home receives is based on their individual needs, so they receive the care they need in the way they prefer. The principles of dignity and privacy are promoted so people who live at the home feel respected and valued. EVIDENCE: CLS Group has a strong belief that it is essential to involve people in the planning of their care, lifestyle and quality of life. The philosophy of the home is that people who use the service should be at the centre of everything they do and they should make decisions about their own care. This is reflected in the organisation’s established care-planning procedures. People who live at the home are provided with a detailed care plan, usually within 48 hours of moving in, which is developed with them and their representatives. Care plans are written in plain language, easy to understand and generally consider all areas of the individual’s life including health, and personal social care needs. All of the people living at the home had a care plan with the exception of one person who had moved in four days before. Observation, records and discussion with the person, their relatives, the Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 12 manager and staff confirmed that the individual’s needs were being met and they had settled in relatively well. However, some staff expressed concern as to the home’s abilities to meet this individual’s needs because of the extent of confusion and disorientation they had experienced when they first moved in. Effective care planning and the development of an orientation programme would have addressed this problem at an earlier stage and would have ensured that all staff had the guidance they needed to meet this individual’s needs and help them get use to the new environment of the home. Some other care plans seen needed reviewing and updating to confirm the changes made to meet the person’s needs. For example one of the people needed one-one support to eat their meals but this had not been recorded in their care plan. In another case District Nurses had given advice on how to meet the individual’s needs associated with their diabetes but this had not been written up in the care plan. Care staff were aware of these changes and knew what to do to meet each person’s needs. However each person’s care plan must be up-dated so all staff including agency staff have access to the information they need to meet the individual’s needs and ensure continuity of care. Risk assessments were carried out in relation to nutrition, moving and handling and risk of pressure sores and falls. People identified as being at risk had relevant care plans in place and were monitored on a regular basis. However, it was noted that fluid and food intake charts relating to one individual were not up-to-date. This meant that staff did not have the information they needed to confirm whether the individual, who was unable to speak for themselves, had enough food and drink. Sixteen people living at the home were spoken with during the inspection all were satisfied with the standard of care provided. All spoke highly of the staff team and made positive comments including “The staff here work very hard to make life comfortable for the residents and treat everyone with love and respect and patience”, “the home and staff are lovely”, “I love the staff here” and I am very happy with the home, they look after me very well. All relatives spoken with during the inspection and those responding to the survey made positive comments about the home and standards of care provided. For example one stated “The care and attention given to residents is excellent”, another stated “All the staff seem to be caring and do the best they can to look after the needs of all the residents” and one said their relative had got used to the place more now and they were quite satisfied with the home, the staff were nice and friendly and there was plenty going on. Case records show that staff work closely with each individuals’ health and social care professionals to ensure that there health and social care needs are met. Visiting district nurses advised that the home provides high standards of Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 13 personal care. Staff and managers were praised for working in partnership, and seeking and acting on specialist advice when required. A nurse manager said, “The staff are skilled and are excellent. They always come to us if they have any concerns and we have a very good rapport with them. Arrangements for the receipt, recording, storage, handling, administration and disposal of medicines are confirmed within the home’s medication policy, which had recently been reviewed and revised. A medications check found that medicines were stored administered and recorded appropriately. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. The routines of the home are planned around the needs and wishes of the people who live there and a programme of activities is on offer. Visitors are made welcome. People are assisted to make choices about their daily lives and the standard of catering is good. EVIDENCE: The atmosphere in the home is relaxed, friendly and welcoming. People who live at Holcroft Grange and their visitors speak highly of the home indicating that the home meets their expectations and they are always or usually satisfied with facilities and services provided. The majority of people spoken with during the inspection said the activities were suitable and they enjoyed them. The activities co-ordinator holds regular meetings with the people who live at the home to seek their views and ensure that activities meet the wide range of tastes and personal requirements represented. Some people choose to entertain themselves and enjoy reading and listening to music. Hobbies and interests are supported and people are encouraged to “be themselves”. For example one of the people who live at the Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 15 home have been able to bring their piano to the home, which is kept in one of the lounges. They said they have always played the piano throughout their lives and it is very important to them. They enjoy playing the piano and entertaining others. The home is supported by a group of volunteers who work with the activities co-ordinator and provide a range of opportunities for social interaction. Other voluntary groups such as the Rotary Club come in to socialise with and entertain people from time to time. People who live at Holcroft Grange are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any reasonable time and facilities are available for them to stay for a meal. People who live at the home can choose to entertain visitors in their own rooms or use one of the lounge or garden areas. The standard of catering in the home is good. All the people spoken with during the inspection said they were happy with the quality and variety of food on offer. Meals are well balanced and menus provide a varied and nutritious diet. Personal preferences and special dietary needs are catered for. However some of the people who live at the home said that the quality of meals can vary when agency staff are on duty. One person who is a vegetarian and is usually satisfied with the variety of meals on offer said “they give me cheese on toast sometimes and I don’t like it”. The cooks know each individuals’ likes and dislikes but the “Kardex” system in the kitchen has not been kept up-todate so agency cooks will not have the information they need to prepare food that meets individual preferences and tastes. Staff were observed to give assistance to those individuals who needed support during mealtimes in a sensitive, discrete and caring manner. Mealtimes are flexible and relaxed, staff are patient and helpful and allow individuals the time they need to finish meals comfortably. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an effective complaints procedure so people can raise their concerns and be listened to. The home uses effective adult safeguarding procedures so people who live in the home are safeguarded from possible abuse or harm. EVIDENCE: The home has a detailed complaints procedure, which provides clear guidance for the people who live at the home and their representatives to make a complaint. Most of the people who live at the home know how to make a complaint. The complaints procedure is provided in large print and plain language so people can read it easily. Records of complaints received by the home show that people are listened to and complaints are investigated and responded to. The home has effective safeguarding procedures including the local authority’s adult protection procedures. Most of the staff have received training on adult safeguarding procedures and have a booklet providing guidance on adult protection so they know what to do in the event of suspicion or evidence of abuse. Further training needs identified via the home’s staff appraisal systems will be addressed in accordance with each staff member’s personal development plan. There has been one adult safeguarding issue since the date of the last inspection. This was handled effectively although there was an initial delay in Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 17 reporting the matter to the local authority. However appropriate action was taken to ensure that vulnerable people are safeguarded from abuse or potential for abuse. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): . 19, 23, and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Holcroft Grange is well maintained so that people at the home live in safe, comfortable, clean and hygienic surroundings that meet their needs and expectations. EVIDENCE: Holcroft Grange is located in the centre of Culcheth village with easy access to the local shops and general amenities. The home provides comfortable and well-equipped accommodation with good quality furnishings and fittings. There is an attractive garden and inner courtyard that provides a safe area for people who live at the home and their visitors to sit and enjoy. People who live at the home are encouraged to personalise their bedrooms, which are furnished and decorated to suit their individual tastes and personal preferences. There is a choice of shared/communal areas including lounges Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 19 and dining rooms so the people who live at the home have opportunities to meet with their relatives and friends in private. People who live at the home say it is comfortable and always or usually clean and fresh. One visiting relative stated, “The cleanliness could not be bettered”. Routine maintenance checks are carried out on a regular basis. Fire doors have been fitted with intumescent strips in accordance with the Fire Officer’s recommendation and a fence has been erected at the rear of the home so people are safe. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are trained, skilled and employed in sufficient numbers to meet the changing needs of the people who live in the home. EVIDENCE: People who live at Holcroft Grange and their visitors’ spoke very highly of the staff team and continue to express confidence in their skills, abilities and commitment. For example one of the people who live at the home stated in the survey questionnaire “The staff here work very hard to make life comfortable for the residents and treat everyone with love, respect and patience”. These sentiments were also reflected in comments made by many other people during the inspection. Many of the people who live at Holcroft Grange have high levels of need for personal and social care. Staff are employed flexibly to meet the varying demands in the home. Ordinarily there are at least four members of the care staff team on duty throughout the daytime period including a Care Team Leader and three care assistants. The manager advised that she had increased staffing levels by employing the activities co-ordinator on care for two hours a day but many staff are concerned that they still have too much to do to meet Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 21 the needs of all the people who live at the home. The manager advised that she is aware that the home is operating at full capacity and is monitoring staffing levels and controlling admissions to ensure that staff are always employed in appropriate numbers. The manager is aware that the number of staff employed must be sufficient to meet the needs of the people who live at the home and she is prepared to raise staffing levels as an when required. Staff were seen to work hard to meet the needs of all the people who live at the home. They operate as an efficient and effective team and carry out their work in good humour with sensitivity, dedication and skill. A number of people who live at the home raised concerns about the high usage of agency staff. They and their visitors felt that the quality of care provided by agency staff did not always match what they had come to expect from the home. Staff rotas and discussion with the manager confirmed that the home had been through a difficulty period when relatively large numbers of agency staff had been used to cover vacancies. However all vacancies had been filled and fewer agency staff were being used as new staff started work. The manager and senior staff had tried to improve consistency and continuity of care by block booking agency staff and ensuring that agency staff were familiarised with the home’s policies and procedures before they started work in the home. Domestic staff including cooks and cleaning staff are employed in sufficient numbers so the catering needs of all the people who live at the home are met and the home is kept clean and hygienic. Holcroft Grange operates thorough recruitment procedures that meet the requirements of the regulations and incorporate equal opportunities and anti discriminatory practice. Staff files contained evidence that all required recruitment checks were in place before the respective individuals were employed. This means that the people who live at the home are safeguarded from the potential for abuse. Management encourage staff members to undertake nationally recognised qualifications beyond the basic requirements, and recognise the benefits of a skilled, trained workforce. Information provided indicates that 12 of the 22 care staff employed have an NVQ level 2 in care or above. The service clearly defines the roles and responsibilities of staff through accurate job descriptions and specifications. There is a comprehensive staff-training programme that has been developed to incorporate “Skills For Care” staff training standards. All staff have had the benefit of an annual appraisal and all have personal development plans. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 22 Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Holcroft Grange is managed in the best interests of the people who live there. Although case records are not always kept up-to-date so staff do not always have access to the information they need to ensure the needs of the people who live at the home are met. EVIDENCE: The manager is competent and experienced to run the home and meet its stated purpose, aims and objectives. She has a City and Guilds in Community Care, a post graduate Diploma in Management Studies, NVQ level 4 in care and the Registered Managers Award. The manager is person centred in her Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 24 approach and leads a strong and committed staff team who have been recruited and trained to a high standard. Managers and staff work in partnership with social and health care professionals to ensure that the needs of people who live at the home are met. The majority of staff spoken with during the inspection feel well supported and appreciate the guidance and leadership provided by the manager and senior staff team. Staff meetings are held on a regular basis and all staff benefit from regular structured supervision. Many staff raised concerns about staffing levels during the inspection. They are committed to meeting the needs of the people who live at the home but feel under pressure due to time constraints and some say they are exhausted. The manager had responded to these concerns by raising staffing levels and managing admissions of new people to the home so staff are employed in appropriate numbers. Records are kept securely and managers and staff are aware of the Data Protection Act and the rights of the people who live at the home to have access to their records. People who live at the home are able to contribute to the development of their assessments, risk assessments and care plans and are invited to sign them to confirm their involvement and agreement. Some records including, care plans, risk assessments and food and fluid intake records were not up-to-date. It is important that these records are updated as and when circumstances change and are kept up-to-date so staff always have access to the information they need to ensure each individuals’ needs are met. Effective quality assurance and quality monitoring process are in place. These are based on seeking the views of the people who live at the home, their relatives, and representatives including health and social care professionals involved in their care. The quality assurance system includes care plan audits; medication audits customer feedback forms, effective complaints procedures and annual satisfaction surveys by questionnaire. The results of this work are published in the current statement of purpose and service users guide so people know what action is taken to address quality issues and improve the standard of care and facilities and service provided. CLS Group seeks to ensure the health and safety of all employees and residents. Risk assessment and risk management is central to the conduct of the home. The manager ensures that risk assessments are carried out for all safe working practice topics and significant findings are recorded and reviewed. Information provided indicates that fire precautions are in place and routine maintenance checks of gas and electrical systems, hoist, electrical appliances, fire alarms, extinguishers and emergency lighting systems are undertaken and are up to date. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 25 Staff understand the principles of equality and valuing diversity. They have benefited from training regarding these issues through “Skills for Care” induction training and on the NVQ training programme. The CSCI guide “A Guide for Providers on Equality and Diversity” has been brought to the attention of staff and put with the home’s operations manual so they have access to the guide when needed. Holcroft Grange DS0000027011.V333284.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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 2 3 Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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 OP37 Regulation 17 (1) (a) 17 (3) (a) Timescale for action Ensure that all records as 15/10/07 detailed in schedule 3 of the regulations are maintained and kept up to date in respect of each person who lives at the home including a care plan, so staff have all the information they need to meet each individuals’ needs. Requirement 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 Refer to Standard OP1 Good Practice Recommendations Ensure that all new or potential residents are provided with a copy of the home’s statement of purpose and service users guide before they move in so they have the information they need to make an informed decision about the home. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 28 2 OP7 3 OP7 3 OP8 4 DO15 Ensure that care plans are drafted, within 48 hours of a person moving into the home so staff have the information they need to meet the individual’s needs in the way they prefer. Ensure care plans are reviewed and where necessary updated to reflect the respective individual’s changing needs so staff always have the information and guidance they need to meet each persons’ needs. Ensure that care plans and risk of falls assessments are reviewed and, if necessary, updated when circumstances change or when a person has a fall so staff know what to do to prevent falls and further injury to the individual. Ensure that the “Kardex” system in the main kitchen is kept up-to-date with the dietary needs and personal preferences of all the people who live at the home so all cooks including agency cooks have the information they need to meet each person’s dietary needs and respect their likes and dislikes. Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holcroft Grange DS0000027011.V333284.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!