Inspection on 26/09/05 for Minster Grange

This inspection was carried out on 26th September 2005.

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

Minster Grange 30/10/06

Minster Grange 07/03/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Minster Grange Minster Grange Minster Road Stourport on Severn Worcs DY13 8AT Lead Inspector N Andrews Unannounced Inspection 26th September 2005 09:00 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 Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Minster Grange Address Minster Grange Minster Road Stourport on Severn Worcs DY13 8AT 01299 826636 01299 827180 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) Mrs Monica Arjan McGlynn Trading as Minster Grange Residential Home Mr Arjan Bhoja Odedra, Mrs Shanta Arjan Odedra Joy Belinda Scharff Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26), of places Physical disability over 65 years of age (26) Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The partners and their individual duties are those set out in the partnership agreement dated 23 May 2005. 17 December 2004 Date of last inspection Brief Description of the Service: Minster Grange is a large, detached building situated on the main Stourport to Kidderminster road approximately one mile from Stourport town centre. The town provides a good range of social and civic amenities. The home is registered to provide residential i.e. personal, care to a maximum of 26 older people above the age of 65 years who may also be physically disabled and/or have a dementia illness. The property has been adapted for its present use as a care home. There is an enclosed garden at the rear of the premises and carparking facilities at the front of the premises. The service users are accommodated in 16 single bedrooms and 5 double bedrooms. All of the bedrooms except three single bedrooms have an en suite facility. The home has both a passenger lift and a stair lift to enable the service users to have easy access to the accommodation on the first floor. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection that took place over a period of one day. The service users’ care plans, staff records and other relevant policies and documents maintained by the home were inspected. Parts of the home were also inspected. Separate discussions were held with five service users and one member of staff. Time was also spent with the registered manager assessing the home’s response to the requirements and recommendation that were made as a result of the previous inspection. The member of staff who was interviewed spoke positively about the home. She stated that the home had a friendly atmosphere and visitors were always made to feel welcome. She also stated that good relationships existed between the staff and the service users. She said that members of the local church visited the home every six weeks and an organist and his wife visited every month to entertain the service users. A small number of service users, usually less than six, attended a sewing activity held in the home by a ‘sewing lady’ for about an hour every fortnight. Some of the service users played Bingo occasionally. She said that although there was a rota for bathing the service users the rota could be changed if necessary. However, she also said that the home had experienced some difficulties in the retention of staff. One of the service users with whom a discussion was held stated, ‘The staff are kind on the whole. I’ve been happy here from the beginning. I have nothing bad to say about the home’. Another service user said, ‘I’ve been here nearly four years and the staff look after me well. The staff have been very kind to me and very helpful. I feel very comfortable here. I can’t fault the care’. Another service user said, ‘The staff are always kind and pleasant. They are all nice. They try to please us. There are no rules or restrictions. You can go to bed and get up when you like’. Another service user commented, ‘The staff don’t make you get up if you don’t want to’. Three of the service users expressed their confidence about raising any concerns with the staff. They also felt confident that any matters of concern would be taken seriously and dealt with appropriately. One of the service users mentioned the registered manager in particular. She described her as a ‘good manager’ and said that she thought highly of her. She said, ‘She always listens to me’. Describing a particular situation the same service user said of the registered manager, ‘She makes it easy. I’m grateful to her’. However, one of the service users said, ’It would be nice if there was someone who could take us out occasionally, say to the shops. It would make a difference’. Another service user stated, ‘We could have more to do’. What the service does well: Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 6 The service users live in clean, comfortable surroundings. A good standard of food is provided. The home has satisfactory laundry facilities. The registered manager stated that the home provided a good standard of care and a high standard of cleanliness. She also said that the service users were always ‘put first’. The service users with whom discussions were held spoke positively about the kindness and helpfulness of the staff. The home has a caring and committed registered manager. What has improved since the last inspection? What they could do better: 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. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 7 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 Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 8 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): N/A It was not possible to form a judgement as none of the Standards in this section of the report were fully assessed. EVIDENCE: The registered manager stated that the home’s statement of purpose and service users’ guide were currently in the form of one document. It was the registered manager’s intention to provide a statement of purpose and service users’ guide that were two, separate and distinct documents. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 9 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 The home maintained care plans in respect of all the service users. However, the contents of the care plans needed to be improved in order to ensure that all aspects of the service users’ needs were met. EVIDENCE: The home’s response to the two requirements that were made in regard to Standard 7 as a result of the previous inspection was assessed. The first requirement was that care staff at the home must review all of the service users’ plans at least once a month. The files of two of the most dependent service users were inspected. It was noted with concern that the contents of the first file were incomplete. The registered manager confirmed that the notes of the most recent review of the care plan had been taken by a member of staff to be written up at home. Therefore, the relevant information was not available for inspection. The registered manager was advised that the service users’ records must be maintained at the home at all times. It was also noted that the service users’ care plan did not contain specific, detailed guidance to the staff on the action to be taken to ensure that all aspects of the service users’ needs were met. It was also noted that parts of the care plan had not been completed e.g. foot care and oral health. In addition, the care plan did not state who would be responsible for meeting the service users’ needs. There were no signatures in the care plan’s signature column. The contents of Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 10 the other service user file were also examined. It was noted that the care plan did not contain clear, specific guidance for the staff regarding the action to be taken to meet the service users’ needs. In effect, the care plan only restated what the service users’ needs were rather than stating how the service users’ needs should be met. The registered manager was given advice on this issue and the distinction that must be made between assessments and care plans. In addition, it was not stated who would be responsible for meeting the service users’ needs and the care plan’s signature column had not been signed. The last recorded review of the care plan was dated 3 May 2005. The requirement had not been implemented. The second requirement was that unless it is impractical, service users or their representatives must be involved in drawing up their individual plans. The registered manager stated that the service users and their families were involved in drawing up the care plans. Therefore, the requirement was regarded as having been implemented. However, the care plans had not been signed by the service users or their relatives. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 11 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): 15 The dietary needs of the service users were appropriately met and the food provided was balanced and nutritious. The menu offered both variety and choice. EVIDENCE: The registered manager stated that breakfast was served between 8:30 and 9:00 am, lunch was served at 12:30 pm, the teatime meal was served at 5:30 pm and supper was served between 7:30 and 8:00 pm. In addition, drinks and snacks were also served mid-morning and mid-afternoon. One service user said, ‘The staff are very good at getting you a drink if you want one’. The registered manager confirmed that some of the service users ate some of their meals in their bedrooms. None of the current service users required their meals to be prepared in a liquefied form. One service user was given a vitamin supplement. However, none of the service users had any special dietary needs because of health, religious or cultural reasons. The registered manager stated that the home catered for the personal food preferences of the service users. It was also stated that none of the service users had any known food allergies. A record of the food provided was maintained. The record showed that the food provided was varied and nutritious. None of the service users required help with feeding. Two service users had their food cut into small pieces. The registered manager said that this help was given in order to assist the service users’ physical ability rather than to avoid any possible risk of choking. One service user who was visually impaired used a plate guard. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 12 The service users with whom discussions were held during the inspection commented positively about the standard of the food provided. One service user described the food as ‘very adequate’. Another service user stated, ‘The food is quite good. It could be better but on the whole you can’t really grumble. We have variety and we had a lovely dinner yesterday’. Another service user said that she ‘enjoyed the food’. She also confirmed that the service users were consulted about the food ‘occasionally but not every day’. Another service user stated, ‘I’ve no concerns. I’m quite happy with the food we get and the service’. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 13 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 The home had a satisfactory complaints procedure. However, the complaints that had been made against the home had not been recorded. EVIDENCE: The home had a complaints procedure. A copy of the complaints procedure was included in the service users’ guide. The copy of the complaints procedure that was displayed in the main hallway did not include the telephone number of the Commission for Social Care Inspection (CSCI). The folder that was maintained by the home for recording any complaints did not contain any entries. The registered manager stated that all concerns of a minor nature expressed verbally by the service users were responded to immediately. This assurance was accepted. However, the registered manager also stated that the home had received several written expressions of concern from the relative of one service user that were not recorded. The registered manager was advised to record these concerns and to maintain a written record of the all of the home’s responses. The registered manager also stated that she had received a complaint from a neighbour earlier in the year that had resulted in a visit being made to the home by the Environmental Health Officer. However, the details of this complaint had also not been recorded. A complaint that had been made direct to the CSCI on 5 September 2005 was investigated at the conclusion of the inspection. The complaint consisted of five elements/allegations. One element was upheld, three elements were not upheld and one element was unresolved. The home had a policy on the protection of vulnerable adults. However, the policy needed to be amended. The name of the previous registered provider must be deleted and replaced with the name of the current registered provider. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 14 The policy must also include a clear statement that all cases of alleged or suspected abuse will be reported immediately to the Adult Protection Coordinator and to the CSCI in accordance with Regulation 37. The policy must include the full name, address and telephone numbers of both agencies. The policy should also refer to the procedure that would be followed if the alleged perpetrator were a member of staff i.e. suspension from duty, without prejudice, pending the outcome of the investigation into the allegations that have been made. The policy must make it clear that the registered persons will not be responsible initially for the investigation of any alleged abuse. The home had a copy of ‘Reporting abuse or mistreatment of vulnerable adults – guidance for staff’. The home had a satisfactory whistle-blowing policy. However, the home did not have a copy of the Department of Health guidance ‘No Secrets’. The registered manager confirmed that no cases of alleged or suspected abuse had been reported to her during the previous twelve months. The registered manager also confirmed that she was aware of her responsibility to report the names of any member of staff who may be unsuitable to work with vulnerable adults for possible inclusion on the POVA list. The home’s response to the recommendation that was made as a result of the previous inspection in regard to Standard 18 was assessed. The recommendation was that the home should have a policy and procedure regarding the service users’ money and financial affairs. It was noted that the staff files contained a statement of the home’s policy on the non-acceptance of gifts. However, the home did not have a policy that covered all of the issues referred to in Standard 18.6. Therefore, the recommendation had not been fully implemented and still stands. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 15 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): 26 The home was comfortable, clean and tidy and suitable laundry facilities were provided. However, the home’s infection control policy and procedures needed to be improved. EVIDENCE: The premises were clean and tidy. The laundry was in a separate building at the rear of the premises and could be accessed by the staff without them having to go through any area where food was stored, prepared or eaten. The laundry floor was impermeable and the floor and wall fishes were readily cleanable. The laundry facilities also included a large commercial washing machine, a spinner and a dryer. The home had a separate sluicing facility. The requirement that was made as a result of the previous inspection to install a wash hand basin in the laundry had been implemented. The home had an infection control policy and procedure. However, the registered manager acknowledged that the policy and procedure needed to be amended/updated using the ‘Guidelines for Infection Control in Care Homes’ provided by the Local Health Protection Unit. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 16 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 and 29 The staffing arrangements were satisfactory and steady progress was being made in regard to NVQ training. However, the staff rota needed to contain more detailed information and the staff recruitment procedures needed to be more robust in order to ensure the safety of the service users. EVIDENCE: A list of all the current staff and the weekly hours for which they were employed was made available for inspection. The registered manager was employed for 40 hours per week. In addition, the home also employed a deputy manager for 35 hours per week, two head senior carers for a total of 43 hours per week and eleven care assistants for a total of 227 hours per week. In addition, one care assistant (16 hours per week) and one night care assistant (18 hours per week) were on maternity leave and one care assistant (18 hours per week) was on long-term sick leave. The home also employed six night care assistants for a total of 99 hours per week, two domestic staff for a total of 40 hours per week, a housekeeper for a total of 35 hours per week, two kitchen staff for a total of 33 hours per week and an administrative assistant for 10 hours per week. The housekeeper’s hours were divided between cooking (15 hours per week), caring (10 hours per week) and housekeeping (10 hours per week). The registered manager stated that there were no staff vacancies. The registered manager gave an assurance that two care assistants were on waking duty at all times during the night. A copy of the staff rota was made available for inspection. The staff rota did not include the hours worked by the registered manager or the names of all the members of staff or their position within the home. The names of the staff that were Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 17 shown on the rota were abbreviated to their initials and the kitchen and domestic staff were not included. The registered manager stated that three members of staff had successfully completed NVQ level 2 training and one member of staff had successfully completed NVQ level 3 training. One member of staff was undertaking NVQ level 2 training and hoped to complete it shortly. It was also stated that several members of staff intended to commence NVQ level 2 training in the near future. It was pleasing to note that the home was making progress in regard to NVQ training. However, the number of care staff who had not undertaken NVQ level 2 training still fell below the expected target of 50 . The contents of the files in respect of four members of staff were inspected. Two of the files contained two written references. However, one of the other files, in respect of a member of staff who had commenced working at the home on 25 July 2005, did not contain any references. The other file, in respect of a member of staff who had commenced working at the home on 6 October 2004, contained two references. However, both of the references were from the same previous place of employment and contained the same information. The requirement, therefore, that was made as a result of the previous inspection that two written references must be obtained before appointing any member of staff had not been implemented and still stands. In addition, one of the four files that were examined did not contain any proof of the person’s identity. The file in respect of one member of staff did not contain any reference to a CRB check. The registered manager stated that 20 members of staff did not have a CRB check. Eight of the 20 staff without a CRB check were staff who been employed directly by the home. Twelve of the 20 staff had transferred from other care homes and had previously undergone a CRB check. The registered manager stated that an application to the CRB had been made in respect of all 20 members of staff. In addition, the home was awaiting the outcome of a CRB check in respect of another two prospective members of staff. The registered manager was advised that CRB checks were ‘non-portable’ and that a new CRB check must be carried out in respect of all new staff appointed to work in the home regardless of the fact that they may have previously worked in other care homes. The deputy manager confirmed that a copy of the code of conduct and practice set by the GSCC had been issued to all of the staff. Three of the four staff files contained a copy of the statement of terms and conditions of employment (contract). The fourth file did not contain a contract and this was because the member of staff was still working her probationary period. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 18 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): 36 and 37 Improvements were needed in regard to staff supervision, quality monitoring and record keeping. EVIDENCE: Standard 31 was not fully assessed. However, it was pleasing to note that the registered manager was currently undertaking NVQ level 4 training. It was also noted that the registered manager had not undertaken any training on dementia care, health and safety or on the protection of vulnerable adults from abuse. It is important that the registered manager undertakes appropriate training in each of these aspects of care. The registered manager had previously agreed to undertake training in health and safety and to develop her knowledge in dementia care through the Alzheimer’s Society prior to her application for registration being approved in April 2005. The home’s response to the requirement that was made in regard to Standard 33 as a result of the previous inspection was assessed. The requirement concerned the introduction of a quality assurance system. The registered Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 19 manager stated that every month an audit report was carried out on the home. Copies of the two most recent reports dated July 2005 and 31 August 2005 were made available for inspection. The audit report forms had not been completed in full and did not indicate to what standard the various issues were being assessed. The audit reports could form an element of a quality assurance system. However, in themselves, they did not constitute a quality assurance system. The requirement, therefore, had not been fully implemented and still stands. The home’s response to the requirement that was made in regard to Standard 36 as a result of the previous inspection was assessed. The requirement was that supervision of all care staff must take place at least six times a year and include all aspects of practice, philosophy of care in the home and career development needs. It was confirmed that forms for recording supervision meetings had been devised that covered all of the relevant aspects referred to in the Standard. However, the registered manager confirmed that staff supervision meetings had not been held. The requirement, therefore, had not been fully implemented and still stands. The registered manager stated that responsibility for carrying out staff supervision would be divided between four senior members of staff. In these circumstances the registered manager should continue to maintain an oversight of the supervision process in order to ensure that it is meaningful and effective. The home’s response to the requirement that was made in regard to Standard 37 as a result of the previous inspection was assessed. The requirement was that all records must be available and maintained to meet the requirements of regulation 17, Schedules 1,2,4 specifically; Staff records must be maintained in accordance with Regulation 17, Schedule 4(6). It was pleasing to note that most of the records that the home was required to keep were being maintained. However, the following issues were also noted, • The records maintained in respect of the service users were in the process of being developed e.g. care plans. • The statements of the procedure to be followed in the event of accidents or in the event of a service user becoming missing should include an instruction that the matter must be reported to the CSCI in accordance with Regulation 37. • The statement of the procedure to be followed in the event of a service user becoming missing should also include an instruction that the matter must be reported to the Police and that a clear, detailed and accurate record of the incident must be maintained. • The statement of purpose and the service users’ guide should be two, separate and distinct documents. • There was no evidence to show that any weekly fire alarm tests had been carried out since 23 July 2005. • There was no evidence to show that the fire doors had been checked since 19 June 2005. Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 20 There were no copies available of the monthly reports made by the registered provider in accordance with Regulation 26 and no copies of the reports had been sent to the CSCI. • There were deficiencies in the staff records, staff rota and record of complaints as indicated in other sections of this report. The requirement, therefore, had not been implemented and still stands. Two immediate requirements in regard to fire safety were issued at the conclusion of the inspection. It was noted that, at the time of the inspection, a lockable door was being fitted to the small office where the service users’ records were intending to be kept. The home’s response to the requirement that was made in regard to Standard 38 as a result of the previous inspection was assessed. The requirement was that there must be at least one member of staff on duty at all times, day and night, who is qualified in first aid i.e. the First Aid at Work course. The registered manager stated that she had undertaken the relevant training. In addition, five other staff had also undertaken the First Aid at Work training i.e. the housekeeper and four members of the care staff including one night care assistant who was on maternity leave. The staff rota showed that during the week of the inspection there were five evenings and two nights where the staff on duty had not undertaken first aid training. The requirement had not been fully implemented and still stands. • Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 21 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 X X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 1 1 X Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 22 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 15,17 Requirement All the records that are held about the service users by the home, including the reviews of the care plans, must be maintained at the home and made available on request at all times. All parts of the service users’ care plans must be completed in full and signed by the staff/registered manager. The care staff at the home must review all of the service users’ care plans at least once a month. (Previous timescale not met) The service users’ care plans must set out in detail the action which needs to be taken by the care staff to ensure that all aspects of the needs of the service users are met. The service users’ care plans must be agreed and signed by the service users whenever capable and/or their representative (if any). A record of all the complaints made against the home and the action taken by the registered DS0000063833.V250672.R01.S.doc Timescale for action 31/10/05 2 OP7 15 30/11/05 3 OP7 15 30/11/05 4 OP7 15 30/11/05 5 OP7 15 30/11/05 6 OP16 17 26/09/05 Minster Grange Version 5.0 Page 23 7 OP18 12,13 8 OP26 12,13 9 OP27 17 10 OP29 17,19 11 OP29 17,19 12 OP29 19 13 OP31 9,18 persons in response to all such complaints must be maintained and made available for inspection at all times with immediate effect. The home’s policy on the protection of vulnerable adults from abuse must be reviewed and, where necessary, amended in accordance with ‘No Secrets’ and the guidance contained in this report. The home’s infection control policy must be reviewed and, where necessary, updated in accordance with the ‘Guidelines for Infection Control in Care Homes’ produced by the Local Health Protection Unit. The staff duty rota must be amended in accordance with the guidance given in this report and a record of whether the staff duty rota was actually worked must be maintained within the home. Two, relevant written references must be obtained before appointing any member of staff with immediate effect. (Previous timescale not met). The records of the staff that are employed by the home must include proof of the person’s identity. Disclosure checks from the Criminal Records Bureau must be obtained for all new staff, including prospective staff who have previously undergone a CRB check, before their appointments are confirmed with immediate effect. The registered manager must undertake training in the protection of vulnerable adults from abuse, dementia care and health and safety. DS0000063833.V250672.R01.S.doc 30/11/05 30/11/05 30/11/05 26/09/05 31/10/05 26/09/05 31/03/06 Minster Grange Version 5.0 Page 24 14 OP33 24 15 OP36 18 16 OP37 17 17 OP37 17 18 19 OP37 OP37 17,23 17,23 20 OP37 26 21 OP38 13 A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 01/04/05 not met). Supervision of all care staff must take place at least six times a year and include all aspects of practice, philosophy of care in the home and career development needs. (Previous timescale of 01/04/05 not met). All records must be available and maintained to meet the requirements of Regulation 17, Schedules 1,2,4 specifically; staff records must be maintained in accordance with Regulation 17, Schedule 4(6). (Previous timescale not met). The statements of the procedure to be followed in the event of accidents and in the event of a service user becoming missing must be amended in accordance with the guidance given in this report. Fire alarm tests must be carried out and recorded on a weekly basis. All fire doors must be checked to ensure that they close properly on their rebate and intumescent strips and smoke seals must be checked to ensure that they are maintained in a satisfactory condition at least quarterly. Visits to the home by the registered provider must take place at least once a month in accordance with Regulation 26 and a copy of the written report on the conduct of the home supplied to the registered manager and to the CSCI. There must be at least one member of staff on duty at all times, day and night, who is DS0000063833.V250672.R01.S.doc 31/01/06 31/01/06 30/11/05 30/11/05 27/09/05 27/09/05 31/10/05 31/01/05 Minster Grange Version 5.0 Page 25 qualified in first aid i.e. the four day First Aid at Work course. (Previous timescale of 01/04/05 not met). 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 OP16 OP18 OP18 Good Practice Recommendations All copies of the home’s complaints procedure should include the telephone number of the Commission for Social Care Inspection. The home should obtain a copy of the Department of Health guidance ‘No Secrets’. A policy should be developed and implemented regarding the service users’ money and financial affairs ensuring service users’ access to their personal financial records, safe storage of money and valuables, consultation on finances in private, and advice on personal insurance; and preclude staff involvement in assisting in the making of or benefiting from service users’ wills. Arrangements should be made for staff to receive training that will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent by 2005. 4 OP28 Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Minster Grange DS0000063833.V250672.R01.S.doc Version 5.0 Page 27 - 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. 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