Inspection on 16/06/08 for Necton Grange

This inspection was carried out on 16th June 2008.

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

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

Other inspections for this house

Necton Grange 29/06/09

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Necton Grange St Andrews Lane Necton Swaffham Norfolk PE37 8HY Lead Inspector Lella Hudson Unannounced Inspection 16th June 2008 08:30 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 Necton Grange DS0000070492.V366557.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. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Necton Grange Address St Andrews Lane Necton Swaffham Norfolk PE37 8HY 01760 724161 01760 720766 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) Caring Homes Healthcare Group Limited Karon Leonard, registration pending Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Older People Date of last inspection 15th March 2007 Brief Description of the Service: Necton Grange is a Care Home providing personal care and accommodation for up to 20 older people. The Home has twelve single bedrooms and four double bedrooms. The double rooms can also be used as single bedrooms. None of the bedrooms are ensuite. The Home is an older building and provides accommodation over three floors. The Home does not have a lift but does have chair lifts fitted to some of the staircases. There is a communal lounge and dining room. The Home has extensive gardens. The Home is situated on the outskirts of the village of Necton and close to the town of Swaffham. The Home was bought by Caring Homes Healthcare Group Ltd in 2007. The Manager started work at the Home at that time and has applied to the Commission for registration. Fees currently range from £299 to £421 per week. The fees are negotiated individually depending on the needs of the residents. Further information about fees can be obtained from the Manager of the Home. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is ONE STAR. This means that the people who use this service experience ADEQUATE quality outcomes. This report contains information gathered about the Home since the last Inspection in March 2007. It includes information provided by the manager, such as the completed Annual Quality Assurance Assessment and through notifications to the Commission. It also includes information gathered during an unannounced visit to the Home which was carried out on the 16th June 2008 between 8.30am and 3.30pm. There were 12 residents living at the Home on the day of the visit with another resident due to move into the Home later that day and one resident in hospital. During the visit we looked around the accommodation, inspected records, spoke to staff, residents and relatives, observed staff supporting residents and also spoke to the Manager. The organisations Area Manager attended for brief feedback at the end of the visit to the Home. We have also included information received within completed surveys from relatives (9), residents (4) and staff (5). Caring Homes Healthcare Group Ltd took over the Home at the end of 2007 and Karon Leonard was appointed as the Manager at that time. She is currently applying for registration with the Commission. The organisation have identified some areas of improvement that needed to be addressed more quickly and have achieved this. They are also in the process of reviewing the service, including the accommodation, and putting together a plan for further improvements that need to be made. This is the first Inspection of the Home since the registration of Caring Homes Healthcare Group Ltd as the owners. What the service does well: The Home is well managed by a Manager who has appropriate experience and is enthusiastic. Staff and residents find the Manager approachable and are confident that she will take action about issues raised with her. Comments about the Manager were made, such as: “Karen is a good manager, she sorts out any problems” “she is approachable and is always available” The residents spoke highly of the staff, saying that they are “marvellous” and that they provide a good standard of care. Staff were observed to support residents in a kind and relaxed manner. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 6 Residents enjoy their meals and said that the cooks talk to them about their preferences and suggestions. They said that they are offered choices about what they would like to eat. Resident and relatives meetings have been introduced and are used to keep people informed about changes at the Home as well as to obtain the views of the residents and relatives. The Home is only registered for up to 20 older people and usually only have up to 17 residents living there when the double bedrooms are used as singles. Residents said that they like living in a small home where they know everybody. Good recruitment practice takes place which includes the necessary checks on staff prior to them starting work to provide protection to the residents. What has improved since the last inspection? The Manager reviewed the medication system and has made improvements to this, including the purchase of more suitable storage for the medication. Changes are being made to the shift patterns for staff so that there is a more cohesive handover time which enables improved communication amongst the staff team. A second member of staff is now on duty in the house over night. This member of staff carries out a sleep in duty and is available if the night staff needs support. The recording systems are in the process of being reviewed and altered to the organisations own recording systems. This includes regular auditing and review of various aspects of the service. All staff are now responsible for additional tasks, such as liasing with health professionals, completing care plans and administering medication. Staff are receiving training and support to enable them to carry out these roles. A new ‘wet’ room has been built with the provision of a level access shower which residents said is easier to use than the bath. After reviewing the mobility needs of the residents an additional hoist was purchased. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Necton Grange DS0000070492.V366557.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 Necton Grange DS0000070492.V366557.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&3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The written information available helps residents to decide whether the Home will meet their needs The pre admission assessments provide information for staff about how to meet residents needs when they first move into the Home EVIDENCE: The Statement of Purpose and the Service User Guide have been rewritten since the organisation took over the Home. These are clear about the services provided at the Home. The residents surveys all state that they received clear information about the Home prior to moving in but it is not known whether they are referring to the current information or that of the previous Proprietors. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 10 We looked at three of the care plans, which include the initial assessment which was undertaken prior to the residents moving to the Home. Only one of these had been completed by the current Manager as the other two residents had moved to the Home prior to this organisation taking it over. The most recent assessment includes information gathered from the resident and other people involved in his life, including healthcare professionals. The staff said that they see the information prior to the resident moving into the Home. The Home does not provide Intermediate Care. Necton Grange DS0000070492.V366557.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 & 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The information within the care plans is not sufficient to ensure that the residents needs are met in a consistent way Residents are not fully protected by the Homes management of medication Residents feel that they are treated with respect EVIDENCE: The previous owners of the Home carried out the majority of tasks such as liasing with GP and other health professionals, the administration of medication and the maintenance of care records. Since the change in ownership of the Home the care staff have been expected to undertake these additional tasks and have received some training to do this as well as receiving ongoing support from the Manager. The Manager said that the recently planned Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 12 training about maintaining records was unfortunately cancelled but that she is liasing with the training manager to rearrange this. Three of the care plans were seen. The organisation has introduced their corporate paperwork for care planning and recording of information relating to the health and personal care needs of the residents. In general, the paperwork is organised and encourages staff to clearly record information. It also includes assessments for issues such as pressure care, falls, moving and handling. However, the corporate care plans are not personalised enough and do not reflect individual needs. They do not specify how the care should be provided. For example, one of the care plans states that the resident should see the ‘Recreational Therapist’. The Home does not have such a therapist and this is confusing for staff. Another care plan for a resident with diabetes states that the ‘dietary regime’ should be complied with but there is no dietary regime recorded. The care plans and daily notes are not recording information in enough detail nor are they cross referenced which makes it difficult for staff to see what action has been taken to address a health need. For example the daily notes for one of the residents states that the diabetic nurse had reviewed one of the residents but there was no information within the care notes about the outcome of this review. Another of the care plans that we saw stated in the daily notes that the resident has a pressure area with a note to say that the resident should be ‘turned occasionally’ but with no details about how regularly or how this should be carried out. The biography and social history sections of the care plans are not completed and so the staff do not have a good understanding of what the lifestyle that a resident used to have, what they are interested in and therefore, what they may like to be involved with now. The residents surveys state that one feels that they ‘usually’ get the care that they need and two state ‘always’ to this question. The residents who spoke to us had different views about how long they have to wait for staff to assist them, with one saying that they do not ever have to wait for long and another saying that they have to wait considerable time on occasions. One of the residents said that the staff are “…very good, we are looked after marvellously”. Another resident said that “…staff are marvellous, very kind, they cant do enough for you”. One of the residents said that the staff are good at explaining what they are doing and to offer choices. For example, one resident said that if she tells staff that she wishes to have a ‘lie in’ in the morning then they come to assist her later in the morning. However, there are at least two residents who use the hoist for all mobility and therefore need two members of staff to assist them. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 13 The current night staffing arrangements are for there to be one waking member of staff on duty from 9pm to 8am and a member of staff doing a sleep in for the same hours. There seems to be some misunderstandings amongst the staff team as they are assisting those residents who need two staff to go to bed prior to 9pm. This takes away the personal choice of the residents and the Manager said that this is not necessary as the member of staff carrying out the sleep in is available to assist the night staff as necessary. She said that she will discuss this with staff as soon as possible. The Home does not have a passenger lift and so residents either need to be able to manage the stairs or to be able to sit on the chair lift attached to the staircases. One of the residents has a room on the second floor and is now unable to use the chair lift and so is unable to come down to the lounge or dining rooms. The Manager said that she will contact the social worker to arrange a review to ensure that the residents needs can still be met at the Home. The Manager has made a lot of improvements with regard to the management of medication. Two new medication trolleys have been purchased and are secured around the Home. A monitored dosage system is used and all staff have received training and the Manager has assessed their competence with regard to the administration of medication. Each member of staff on duty is responsible for the administration of medication for the ‘half’ of the Home that they are working in. The Manager said that this prevents duplication and misunderstandings. The PCT pharmacist has undertaken an audit of the medication system at the Home and assessed the procedures as being satisfactory and that the Home are following these. They identified that there were some gaps in the administration records which the Manager had also identified within her monthly medication audits. We also saw that there were some gaps within the administration records which means that it is not clear whether residents are receiving their medication at appropriate times or not. The Manager has taken action to address this problem. Necton Grange DS0000070492.V366557.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 & 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are not supported to take part in meaningful activities on a regular basis Residents are supported to maintain contact with family and friends Residents are helped to exercise choice and control in a limited range of issues affecting their lives Residents receive an appealing, balanced diet EVIDENCE: The activities co-ordinator is currently on long term sick leave and one of the other members of staff is undertaking this role for five hours per week. The staffing levels are not currently sufficient to enable staff to organise activities on a regular, planned basis and so these tend to take place in a more informal basis during the afternoons when staff have time to do so with some additional planned outings taking place over the summer. Two of the residents told us Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 15 about the enjoyment that they got from a recent trip to the zoo and how they are looking forward to a forthcoming trip to Hunstanton. Residents also told us that activities do not take place on a regular enough basis and that they would enjoy being involved in a lot more activities. One of the residents said that he was “bored” and that he would like to “do more things”. Additional comments made in the relatives surveys state that there needs to be more stimulation/activities taking place at the Home. The social interests section of the care plans are not completed adequately to enable staff to have some idea about residents previous interests or what they might like to be involved with now. We sat in the lounge for 45 minutes looking at records during the afternoon and one member of staff came in to ask a resident if they would like the television turned up. The rest of the time staff did not come into the lounge or interact with the residents, most of whom fell asleep. The responses within the relatives surveys are positive about the fact that staff keep them informed about issues affecting their relative. Residents said that they are able to have visitors whenever they like. The Manager has implemented residents/relatives meetings and said that these are becoming more well attended. The minutes show that the views of residents and relatives are sought at the meetings. For example, the Manager played a CD of a music group to the meeting to seek peoples views about which group should be asked to provide the music at the forthcoming summer fete. One of the residents has recently organised a fund raising event within the Home. One of the residents told us that she is able to choose what she does with her time and another resident said that she does not have to wait long for her call bell to be answered if she needs staff to assist her. Residents are supported in their choices but these mainly refer to everyday situations such as where they wish to spend time during the day and what they would like to eat rather than any choices about social activities and maintaining interests that they had previous to moving into the Home. The responses within the residents surveys are mixed with regard to the quality of the meals but the residents who spoke to us on the day of the visit were very positive about the quality and choices that they have with regard to meals. One of the residents is able to get her own breakfast as she chooses to get up very early. Another resident said that the food is “beautiful” and that “we always get a choice, even if we choose something that isn’t on the menu”. The minutes of the residents meeting show that the cook recently attended the meeting and spent time with each of the residents gathering information about their dietary likes and dislikes. The timing of the meals has recently been altered slightly following discussion at the residents meeting. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 16 The Home has kitchen staff during the mornings and up until 2pm but there are no dedicated kitchen staff during the afternoons/evenings. Whenever possible, the kitchen staff prepare tea prior to leaving and so it is the responsibility of the care staff to serve this and to clear up afterwards. This means that the number of care staff available to the residents is reduced to one at these times. At present this does not seem to be presenting a problem but this will need to be reviewed as the needs of residents change and if there are further increases in the number of residents living at the Home. The Manager said that she has received training about the nutritional assessment tool which is advised by the dietary service in Norfolk but that this will not be implemented until staff have received training. The care plans contain information about individual residents dietary needs. Residents usually have breakfast in their rooms and can also choose to have other meals in their rooms if they wish to. The dining room is nicely set out and one of the residents said that they enjoy setting the tables. The dining chairs do not have arms on and this can make it difficult for some of the residents to get up from the chair. The Manager said that this is being considered as part of the organisations complete review of the accommodation that is being carried out. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 17 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 & 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents and relatives are confident that their complaints will be dealt with appropriately Training and supervision provides increased protection to residents from abuse EVIDENCE: The responses within the surveys received from relatives and residents indicate that the majority are aware of the complaints procedure and are confident that their complaints will be listened to and acted upon appropriately. Residents told us that they feel happy to raise any issues with the Manager. The minutes of the residents meetings show that residents are encouraged to raise any issues that they may have. Staff surveys show that staff are aware of the complaints procedure and are aware of what to do if someone wishes to raise a concern/complaint. The Manager said that she has not received any complaints since the organisation took over the Home. The Commission has not received any complaints either. Staffing records show that staff receive training with regard to Safeguarding but that this has traditionally been through the use of video training followed by questionnaires. The Manager said that additional training is being planned Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 18 for all staff to ensure that their knowledge is up to date. Staff who spoke to us were aware of the procedure to follow if they were concerned about possible abuse. The Manager is aware of the correct procedure to follow following an allegation being made. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 19 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, 22 & 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The standard of the accommodation and provision of equipment does not meet all of the residents needs EVIDENCE: We were shown around the Home. We saw all of the communal areas, including bathrooms but only saw three of the bedrooms. The organisation has recently undertaken a full review of the accommodation and equipment provided and so are aware of the areas which need improvement. They are now in the process of putting together a plan for refurbishment and redecoration. The Home is set in its own grounds and is accessed up a long driveway. There is inadequate lighting on the driveway and in the car parking areas. The Home Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 20 has a large, well maintained garden which residents said that they enjoy sitting in when the weather allows. Following a review of the mobility needs of the residents an additional hoist was purchased but there are still not enough hoists to ensure that residents are able to have access to one whichever level of the Home they are on. The lack of a passenger lift within the Home restricts the movements of at least one of the residents who has a room on the second floor. The quality of furnishings and carpets in the bedrooms is varied and there is a need to replace some of the carpets and furniture. There is also a need to replace bedding and mattress covers as the quality of some of these is poor. There is evidence that residents are encouraged to personalise their rooms with their own furniture, pictures and ornaments. None of the bedrooms are ensuite and there are toilets and bathrooms situated around the Home. The baths are not suitable for all of the residents as they are an older style bath which only enables residents to sit in a small area. The bathrooms are in need of redecoration and the flooring needs to be replaced. The organisation are aware of the difficulties that the current bathrooms present and have provided a new “wet” room on the ground floor. This provides a level access shower as well as a toilet and handbasin. This room is almost complete. Access to this room may be difficult for some residents as it is access via a slope and there is currently no differentiation between the slope and the rest of the floor. The majority of bathrooms/toilets have locks which are not able to be overridden in the event of an emergency or do not have a lock at all and this situation needs to be addressed. The Manager said that the hot water is not regulated in all baths/basins but that a check of the temperatures is kept on a weekly basis. This was not seen during the visit. The Home has a large lounge and a separate dining room. As previously mentioned the chairs in the dining room are not suitable for all of the residents as they do not have arms to assist residents to get up. The majority of the doors within the Home are heavy fire doors. Residents said that they can find these difficult to open. There are also no suitable “closures” fitted to these doors and so they always swing shut. The majority of the doors bang loudly when they shut. However, it was noted that at least two of the doors were “wedged” open which presents a fire risk. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 21 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): 27, 28, 29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The needs of the residents are met by the staff team The recruitment practice provides protection for the residents EVIDENCE: The Manager has reviewed the shifts which the staff were working and has changed them so that staff now start at the same time rather than having staggered start times. This means that a formal handover can take place which enables the staff to receive detailed information about the residents from the staff on the previous shift. The rota does not allow for any crossover of shifts and so to enable this to take place we were told that staff either come in earlier or stay later which is unpaid. The current staffing levels are sufficient to meet the care needs of the residents although, as previously evidenced in this report, the provision of activities and leisure activities could be improved. Only personal laundry is carried out on the premises. Residents said the following about the staff: “staff are marvellous, very kind” Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 22 “they really look after you well” “staff are all lovely….” “get looked after marvellously” During the visit to the Home we observed that staff supported residents in a kind and caring way. There was relaxed and friendly communication between residents and staff. Staff who we spoke to know the residents well and are keen to provide a good service. The keyworker system has recently been introduced and this has given staff additional responsibilities with regard to reviewing care plans and ensuring that the needs of specific residents are met. The previous owners of the Home lived on the site and so night time support was provided by them. Over the last few months there has been a waking night care staff who has been supported by a “sleep in” member of staff but this second person has not always been on the site and may have been at their own home in the village. The organisation has recognised that this situation was not acceptable and has provided a sleep in room within the Home for the second night staff to use. The Manager is currently having a lot of difficulty in finding staff to cover the sleep in shifts and the waking night shifts. Staff from other Homes owned by the organisation are providing support with covering these shifts. Although the Manager has managed to cover these without having to employ agency staff who do not know the residents it does take up a lot of her time to arrange staffing. We were told that recruitment is ongoing. The staff surveys all state that they feel that they receive good training which is relevant to their role. The training records show that the majority of the training which staff received prior to this organisation taking over the Home was provided through the use of training videos followed by questionnaires. The Manager and area manager have reviewed the training that staff have received and there are plans in place to provide additional training for staff in a variety of areas relevant to the needs of the residents. Some training will be provided by external trainers and some by the organisations own training staff. The organisation are also introducing elearning through computer programmes. The Manager is planning to attend Training the Trainers course with regard to moving and handling so that she is able to provide this training to the staff. A selection of staff files were seen and these contain the necessary checks on staff which are carried out prior to them working at the Home. The responses in the staff surveys confirm this. The Manager said that she is discussing with some of the residents their involvement in the recruitment process. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 23 Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 24 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, 32, 33, 35 & 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents benefit from living in a Home which is well managed The residents financial interests are safeguarded There health and safety needs of the residents are not fully protected EVIDENCE: The Manager has worked at the Home since the organisation took it over in 2007. She is currently in the process of applying for registration with the Commission. The Manager receives support from the area manager who Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 25 provides formal supervision and carries out the monthly providers visits. The Manager has relevant experience and has worked as a Manager previously. Staff and residents told us that the Manager is approachable and enthusiastic. Some of the comments include: “Karen is a good manager, she sorts out any problems” “she is approachable and is always available” Regular staff meetings take place and these include the ancillary staff as well as the care staff. Staff said that the Manager is “on call” when she isn’t at work and that she is always available if they need to speak to her. The Home does not have an administrator but the Manager received some administration support during the first few months that the organisation took over the Home. The organisation has a lot of systems in place for auditing and recording aspects of the service provided. This means that the Manager has a lot of administration to undertake in the absence of a dedicated administrator. In recognition of this the organisation has recently promoted one of the care staff to ‘senior carer’ with additional responsibilities. This member of staff is receiving training from the Manager with regard to this role. The weekly and monthly audits of different aspects of the service are monitored by the Manager as well as other people within the organisation such as the Area Manager and the Quality Assurance Manager. The Manager gave examples of action that has been taken following audits, such as steps to improve the medication system. The Manager told us that residents and relatives have recently completed questionnaires about the service provided and that these have been sent to the organisations headquarters to be analysed. A sample of records were seen which relate to residents finances which are looked after on their behalf. The records tallied with the receipts and cash held. The system used is transparent and allows for easy audit. The Manager said that health and safety training will be provided for staff. There are systems in place to protect the health and safety of residents and staff. For example, chemicals and cleaning products are appropriately stored and the Manager said that a full Fire risk assessment has been carried out but that she has not yet received the report. However, there are some areas which need addressing which have previously been mentioned in this report. For example, there are not enough hoists within the Home to meet the needs of residents who may fall and fire doors were seen to be propped open which presents a risk in the event of a fire. The hot water is not regulated in all areas which also presents a risk. The information in the care plan about how staff should dispose of cigarette ends Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 26 belonging to the one resident who smokes is not clear and this may also present a fire risk. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 27 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 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 3 3 X 3 X X 2 Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 15 (1) Requirement The care plans must contain detailed information about individuals care needs go ensure that residents needs are met The medication administration records must be accurate to ensure that residents receive the correct medication at the correct time Social activities must be provided which meet the residents needs Suitable equipment such as hoists, baths and locks must be provided to ensure that the needs of the residents are met Suitable bedding must be provided which meets the needs of the residents and ensures that they are comfortable and warm The bathrooms must provide suitable equipment to meet the needs of the residents in rooms which are well decorated The fire doors must have appropriate closures which enable residents to have their doors open if they wish to A safe system must be in place DS0000070492.V366557.R01.S.doc Timescale for action 31/08/08 2 OP9 13 (2) 16/06/08 3 4 OP12 OP19 16 (m) & (n) 23 (2) (n) 31/08/08 31/08/08 5 OP19 16 (2) (c) 31/07/08 6 OP22 23 (2) (b) 30/09/08 7 OP38 13 (4) (c) 31/07/08 8 OP38 13 (4) (c) 30/06/08 Page 29 Necton Grange Version 5.2 with regard to the hot water to protect the residents from scalding/burns 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 OP19 Good Practice Recommendations It is recommended that suitable lighting is provided in the driveway and car parking areas of the Home. Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE 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 Necton Grange DS0000070492.V366557.R01.S.doc Version 5.2 Page 31 - 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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