Inspection on 02/06/06 for Holcroft Grange

This inspection was carried out on 2nd June 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

Holcroft Grange 13/09/07

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 Key Unannounced Inspection 10:30 2 and 9th June 2006 nd 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.V292139.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. Holcroft Grange DS0000027011.V292139.R01.S.doc Version 5.1 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.V292139.R01.S.doc Version 5.1 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. 9th November 2005 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 all service users 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. Information provided by the registered manager on the 9th June 2006 confirms that fees range from £430 to £460 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.V292139.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 2nd and 9th June 2006 over a 10 and a half hour period. The inspection takes into consideration the developments in the home since the date of the previous inspection. It is focused on the experiences of residents and their representatives. The views of residents, their representatives including family members and health and social care professionals were gathered by survey questionnaires before the inspection and nine residents were spoken with during the inspection. A tour of the premises was conducted and some records were read. The registered manager and a number of staff were spoken with and observation was made of their practice in the delivery of care. What the service does well: Holcroft Grange is ideally located in the centre of Culcheth village with easy access to the local shops and general amenities. The home provides comfortable, well-equipped and nicely decorated accommodation. It is well maintained with good quality furnishings and fittings. There is an attractive garden and inner courtyard that provides a safe area for residents to sit and relax. Residents and visitors speak highly of the staff team. They are skilled and knowledgeable about the needs of residents. They share a common purpose to provide high standards of care and work to put the values polices and practices of CLS into practice. They say residents come first and this is reflected in the their approach and the positive feedback they receive from residents and their representatives. Management encourage staff members to undertake nationally recognised qualifications beyond the basic requirements, and recognise the benefits of a skilled, trained workforce. 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.V292139.R01.S.doc Version 5.1 Page 6 The atmosphere in the home is welcoming and sociable and at times is positively buzzing with activity. Residents are able to choose from a range of activities and are assisted to visit the local shops and engage with the local community in a number of ways. The standard of catering is good. Choice is offered with every meal; special diets, residents’ likes and dislikes are known and catered for. Effective quality assurance and quality monitoring processes are in place. These are based on seeking the views of residents and their friends, relatives and representatives. These include care plan audits, medication audits customer feedback forms, effective complaints procedures residents meetings, and annual residents and relatives survey questionnaires. The product of this work is published in the current statement of purpose and service users guide. What has improved since the last inspection? What they could do better: The recommendations of the fire officer must be addressed to ensure that residents are protected from the effects of smoke, as far as possible, in the event of a fire, and action must be taken so residents are protected from local youths who have harassed them in the past. Deficiencies in risk of falls assessment and the prevention of falls that were identified at the previous inspection have not been addressed effectively. CLS have provided detailed guidance on the prevention of falls but this has not been put into practice despite further concerns raised by senior management. Holcroft Grange DS0000027011.V292139.R01.S.doc Version 5.1 Page 7 The manager must ensure that care staff have the leadership, guidance and feedback they need to ensure that residents needs are consistently met. Senior care staff meetings and care staff meetings are important ways of ensuring that staff receive the support and feedback they need. The manager should make sure that these are held on a regular basis in the interest of good communication and staff support. Appropriate stock records of loose medication must be made and maintained so the manager can complete effective medication audits. Action must be taken to make sure that agency staff have the necessary skills, abilities and commitment to ensure that residents needs are met. This is important as the home relies on agency staff to cover care staff absences when contracted staff are unavailable. Care staff should not be employed unless all appropriate checks including criminal records and protection of vulnerable adult register checks have been made. Unless the manager implements the organisation’s thorough recruitment checks in full residents will not receive adequate protection. 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. Holcroft Grange DS0000027011.V292139.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 Holcroft Grange DS0000027011.V292139.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, 2 and 3. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. New residents and their representatives have the information they need to make an informed choice about the home. EVIDENCE: All new residents are provided with a detailed information pack that includes the statement of purpose, service users guide and terms and conditions. They are offered opportunity to visit and test-drive and are able to discuss its suitability with senior staff before they make any decisions about moving in. Each new resident has an appointed key worker whose job it is to pay particularly close attention to the individual’s needs and wishes whilst also acting as a support and friend to help them settle in. Holcroft Grange DS0000027011.V292139.R01.S.doc Version 5.1 Page 10 Case records contain appropriate pre-admission and assessment documentation. Most case records include contracts or terms and conditions documents and written confirmation that the home is suitable to meet the resident’s needs. However only one of the four residents who had most recently moved in had a contract of statement of terms and conditions on their file. See recommendation 1. Holcroft Grange DS0000027011.V292139.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Arrangements for health and personal care are based on their individual needs and the principles of respect, dignity and privacy are put into practice. EVIDENCE: The service has a strong belief that it is essential to involve residents in the planning of care that affects their lifestyle and quality of life. Each resident has a plan that has been agreed with him or her or their representatives. This is written in plain language, is easy to understand and generally considers all areas of the individual’s life including health, and personal social care needs. Reading of care plans and discussion with staff, residents and their representatives confirms that arrangements for care are reviewed and evaluated according to the respective individuals changing needs. However, two of the care plans seen require further developmement to confirm changes including new arrangements to meet residents’ needs. In one case the resident had suffered a series of falls and had been lethargic for some time. A risk of falls assessment was in place but this was not complete and did not provide a conclusion. The care plan had only been updated to reflect that the risk of falls Holcroft Grange DS0000027011.V292139.R01.S.doc Version 5.1 Page 12 assessment was in place. Senior staff were unable to advise what action had been taken to manage the risk of falls but they were aware that the resident’s medication had been reviewed and the affects of this had not settled down. The resident advised that she was exhausted and had been so for a number of days. This was not recorded in the case records but a senior member of staff had taken a urine sample and passed this to the General Practitioner’s (GP’s) surgery. The reason for the urine sample was not clear from the records but the member of staff who sent it to the GP advised that she was concerned as to the individual’s condition but had not recorded her concerns. In another case a resident had returned from a stay in hospital and presented with nutritional and pressure area care needs. There was evidence that staff were attending to these needs but the care plan had not been updated. The registered persons must ensure that risk of falls assessments are completed appropriately and case records are sufficiently detailed so all staff know what action has `been taken to meet residents’ needs. See requirement 1 and 2. Residents speak highly of the standard of care provided. They say they are treated with respect and are appreciative of the way staff support them on visits to the clinic and on Doctor’s appointments. Staff monitor residents’ health and well-being and make contact with health and social care professionals when required. One group of visitors spoke of the excellent standards of care provided. Their relative had made a significant recovery after a stay in hospital, thanks to the staff at Holcroft Grange. They said she was well on the mend both physically and in herself. Appropriate arrangements are in place for the administration and safe storage of medicines with the exception that stock records of medicines brought into the home are not maintained in the appropriate detail. See requirement 3. Holcroft Grange DS0000027011.V292139.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, 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 residents’ needs and wishes and a programme of activities is on offer. Visitors are made welcome, residents are assisted to make choices about their daily lives and the standard of catering is good. EVIDENCE: The atmosphere in the home is relaxed, sociable and welcoming. Residents and their visitors speak highly of the home indicating that it meets their expectations and they are satisfied with facilities and services on offer. There is a lot going on. The home has an activities co-ordinator who is new and well regarded. She and other staff enable residents to make full use of opportunities for social interaction in the local community. The activities programme is posted in each resident’s room and residents routinely join in with local coffee mornings and like to watch line dancing. The home is supported by a group of volunteers who provide a range of activities and other voluntary groups such as the Rotary Club come in to socialise with and entertain residents from time to time. Holcroft Grange DS0000027011.V292139.R01.S.doc Version 5.1 Page 14 Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them to have a drink or a meal with the resident. Residents can choose to entertain visitors in their own rooms or the lounge or garden areas. Maintaining independence and helping residents to make their own decisions about how they wish to live is a key objective of the home as stated in the information pack and “Service Users’ Charter”. The routines of the home are planned around residents’ needs and wishes. Resident say that there are no rules, they get up when they want and go to bed when they want. It’s up to them what they do. One resident said that she is not able to go out on her own because of safety issues. She said that she had agreed this with staff and from time to time they take her out for a walk to allow her to stretch her legs. The vast majority of residents returning questionnaires and all those spoken with said the food is always good. Special dietary needs are catered for and menus confirm that a varied and nutritious diet is on offer. Residents are routinely consulted on the quality of meals and menus are discussed at residents meetings. Holcroft Grange DS0000027011.V292139.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Satisfactory arrangements are in place for the protection of vulnerable adults and making complaints. EVIDENCE: The home has a clear complaints procedure that establishes the importance of making complaints so action can be taken to put things right. All comments and complaints are welcomed. Information provided indicates that there has been one complaint in the previous 12-month period. A record is kept of all complaints made and includes details of investigation and how matters were resolved. Robust procedures for responding to suspicion or evidence of abuse or neglect are in place including whistle blowing as in accordance with the Public Interest Disclosure Act 1998. Staff have received a booklet providing guidance on the implementation of adult protection procedures. 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 protection issue since the date of the last inspection. This was handled effectively. It was reported in accordance with the home’s policies procedures and the requirements of the regulations. Holcroft Grange DS0000027011.V292139.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. The accommodation is good but action must be taken to provide a safe environment for residents, staff and visitors. EVIDENCE: Holcroft Grange is ideally located in the centre of Culcheth village with easy access to the local shops and general amenities. The home is well maintained with good quality furnishings and fittings. There is an attractive garden and inner courtyard that provides a safe area for residents to sit and relax. Three residents and one visiting relative raised concerns about local youths who are said to come into the grounds of the home at night time. There is no fence to the side of the home. The youths gain access by a public footpath and generally congregate on a patio area at the back of the home. They make a nuisance of themselves peering into residents’ rooms and on occasion have Holcroft Grange DS0000027011.V292139.R01.S.doc Version 5.1 Page 17 climbed on the roof causing residents to be frightened and anxious. Residents say that staff call the police but when they arrive the youths run off and the problem has persisted too long for some. It is understood that a fence is to be erected but there is no indication as to when. See requirement 4. A requirement made at previous inspections to fit fire doors that have not already been upgraded with in-tumescent strips and smoke seals, in accordance with the recommendations of the fire officer, had been addressed in part. The work has been referred to the organisations property services department but no significant progress has been to address the problem. There are no smoke seals on some communal and connecting bedroom doors. See requirement 5. Holcroft Grange DS0000027011.V292139.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Staff in the home are trained, skilled and employed in sufficient numbers to meet the changing needs of residents. EVIDENCE: Residents have confidence in the staff that care for them. They say that they are kind and considerate. One said that the staff are lovely. Visiting relatives describe the staff team as excellent they say staff know residents’ needs and care for them very well. Discussion with the manager indicates that 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 day time period including a Care Team Leader and three care assistants. Numbers of residents accommodated have fluctuated from 30 to 36 in recent weeks and care staff have been employed accordingly at the approximate ratio of 1:10. Visiting relatives speak highly of the staff team but some are concerned that staff are not always employed in sufficient numbers. One said when they are working with just three care staff including one Care Team Leader and two care assistants they are rushed. There is no indication that residents’ needs are not met but residents have to wait and staff do not have the same time to sit and talk with them. Senior staff advised that they try to ensure that the 1: 10 ratio is met but say this is not always possible due to holidays and sickness. Holcroft Grange DS0000027011.V292139.R01.S.doc Version 5.1 Page 19 They advise that they always try to cover gaps in the rota from within the staff team and will go to great lengths to achieve this in the interests of continuity of care. Reading of the rota indicates that one staff member was rostered on duty to do two consecutive shifts over a 16-hour period. This is contrary to CLS policy and is likely to result in the respective staff member suffering fatigue before the end of the shift. This may adversely affect her ability to meet residents’ needs. Senior staff said they are reluctant to use agency staff because they are not confident in their abilities to work as a team and meet residents’ needs in a consistent manner. Arrangements have been made to ensure that all agency staff are appropriately inducted but these arrangements have not always been put into practice. See recommendation 2. 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 10 of the 21 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. Staff carry out their duties with sensitivity and skill. They were observed to interact with and respond to residents in an appropriate manner. There is evidence mutual respect between both parties. The organisation`s recruitment procedures are designed to be thorough in the interests of the protection of vulnerable people. However, reading of staff files indicates that a member of staff who had been previously employed at the home had been reemployed after a four month gap without an application form, references, criminal records check, protection of vulnerable adults register check or appropriate references in place. See requirement 6. Holcroft Grange DS0000027011.V292139.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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. The manager is qualified and has the necessary experience to run the home but some staff lack the leadership they require and the organisation’s policies and procedures are not put into full effect. EVIDENCE: There is a good staff team at Holcroft Grange they work well together and benefit from a shared sense of purpose, “Residents come first”. Staff are positive in their approach and work to put the organisations policies and procedures into practice. Senior management monitor effectiveness by various means including quality audits and visits to the home in accordance with the requirements of the regulations. Management processes generally ensure that staff receive appropriate levels of feedback but it is noted that deficiencies in care planning and risk of falls assessment identified at a management visit in Holcroft Grange DS0000027011.V292139.R01.S.doc Version 5.1 Page 21 early May had not been appropriately addressed by the 2nd of June 2006. Deficiencies in risk of falls assessment and in the prevention of falls were identified at the previous inspection. The manager advised that she had acquired the National Institute of Clinical Excellence guidance on the prevention of falls in older people and CLS had also produced a pack on falls prevention. The manager said that she had raised staffs’ awareness of these but had not had chance to go through them with all senior care staff as yet. Care Team Leaders confirmed that they are aware that CLS have recently introduced a pack on the prevention of falls. This was raised at a staff meeting but they had not gone through it in detail. The registered persons must ensure that the home is managed to promote and make proper provision for the health and welfare of residents. Where deficiencies in risk assessment and care planning are identified immediate action must be taken to address them. See requirements 1, 2 and 7. 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 and is currently working towards NVQ level 4 in care and the Registered Managers Award. She has completed all course work and is awaiting certification. Staff have confidence in the manager’s abilities but some indicate that she has been distracted by her course of study and the levels of leadership they have come to expect have diminished. The manager said that she has had to put a lot of her available time and her own time into her course of study and has delegated some duties to the Care Team Leaders. She said she knows that some things may have slipped. For example Care Team Leader meetings and care staff meetings have not been held at the appropriate frequencies and one was cancelled because the manager had double booked. Induction training for agency staff, which is vital for ensuring that residents’ benefit from continuity of care has not been put into practice. However the manager’s course of study has come to an end and she has every confidence that she will now be able to provide the staff team with leadership and appropriate levels of support. See recommendations 2 and 3. Effective quality assurance and quality monitoring process that are based on seeking the views of residents and their friends, relatives and representatives are in place. These include care plan audits, medication audits customer feedback forms, effective complaints procedures and annual residents and relatives survey questionnaire. The product of this work is published in the current statement of purpose and service users guide. Information provided by the manager and staff indicates that all staff have the benefit of regular formal supervision meetings with their respective line manager. Holcroft Grange DS0000027011.V292139.R01.S.doc Version 5.1 Page 22 Some staff are not conversant with issues around equality and diversity. The manager advised that there are policies on equality and racial harassment but it is likely that these have not been promoted in recent years. Some residents have expressed views about black care workers based on racial prejudice. The manager is aware of this but has not taken action to explore how these issues should be addressed. The values and beliefs of the home and CLS underpin equality and diversity issues but these issues are not being actively promoted. See recommendation 4. The manager ensures that residents are able to control their own money, except where they state that they do not wish to or they lack capacity and other arrangements are made. Residents may deposit small amounts of money with the home for safekeeping. Appropriate records and receipts are maintained. The company 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. However action must be taken to address the recommendations of the fire officer to upgrade fire doors and ensure smoke seals are fitted as appropriate. See requirement 4. Holcroft Grange DS0000027011.V292139.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 3 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X 3 2 X 2 Holcroft Grange DS0000027011.V292139.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 OP7 Regulation 15 Requirement The registered persons must ensure that care plans are updated as and when the needs of residents change. The registered persons must ensure that risk of falls assessments are completed and arrangements to prevent further falls are identified and put in place as far as is possible. (Previous timescale 31/12/05 not met) The registered persons must ensure that comprehensive stock records are maintained of all loose medicines. The registered persons must fit fire doors that have not been already upgraded with intumescent strips and smoke seals, in accordance with the recommendations of the fire officer. (Previous timescale 28. February; 31.May 2005 and 11th February 2006 not met). Timescale for action 09/06/06 2 OP8 12 and 13 09/06/06 3. OP9 13 09/06/06 4. OP19 23 30/06/06 5 OP19 23 The registered persons must 31/07/06 take appropriate action to ensure DS0000027011.V292139.R01.S.doc Version 5.1 Page 25 Holcroft Grange 6 OP295 19 7 OP31 12 the security of the premises and the protection of vulnerable people. The registered persons must ensure that staff are recruited in accordance with the requirements of the regulations and the National Minimum Standards. The registered persons must ensure that the home is conducted in a manner that ensures the well-being of residents. 09/06/06 09/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP2 OP27 Good Practice Recommendations The registered persons should ensure that each resident is provided with a contract or statement of terms and conditions at the point of moving in to the home. The registered persons should improve and record arrangements for the induction of agency care staff to ensure that they are familiar with the home and the needs of residents. The registered persons should explore and implement measures to proactively promote equality and diversity in all aspects of service delivery and staff development. The registered persons should ensure that senior care staff meetings and care staff meetings are held on a regular basis to support staff and ensure good communication. 3. 4 OP32 OP36 Holcroft Grange DS0000027011.V292139.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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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