Inspection on 21/05/07 for Northwick Grange

This inspection was carried out on 21st May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Northwick Grange 31/05/06

Northwick Grange 02/03/06

Northwick Grange 20/06/05

Northwick Grange 30/11/04

Northwick Grange 08/06/04

Northwick Grange 09/02/04

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 Northwick Grange 19 Old Northwick Lane Worcester Worcestershire WR3 7NB Lead Inspector Andrew Spearing-Brown Key Unannounced Inspection 21st May 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Northwick Grange DS0000018666.V334481.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. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northwick Grange Address 19 Old Northwick Lane Worcester Worcestershire WR3 7NB 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) 01905 453916 chris.bradley@redwoodcare.co.uk Northwick Grange Limited Georgina Betty Moss Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (32), of places Physical disability over 65 years of age (32) Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31/05/06 Brief Description of the Service: Northwick Grange is a Georgian house, situated in a residential area on the outskirts of Worcester. It was first registered in 1993, and is part of the Redwood Care Home group. The home is on three floors and has a stair lift in place. Northwick Grange provides personal care for a maximum of thirty- two older people who may have a physical disability and or a mental health need associated with the ageing process. A comfortable lounge and dining room are provided on the ground floor. The fees at Northwick Grange currently range from £353 to £360 per week. Additional charges are made for services such as hairdressing, private chiropody and newspapers. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One regulation inspector based at the Worcester office of the Commission for Social Care Inspection (CSCI) undertook this unannounced key inspection over two days. The previous inspection which was also unannounced took place during May and June 2006 This inspection takes into account any information received by the CSCI in relation to the home since the previous inspection as well as the visits to the home. Prior to this inspection a pre inspection questionnaire was posted to the home for completion, this document was returned to the commission. A number of questionnaires were also sent to the home to be completed by residents, relatives and health and social care professionals. A number of completed questionnaires were returned to the commission, the contents of these are taken into account as part of this inspection. The questionnaires from residents (a total 4) were completed with assistance from a member of staff. At the of completing the pre-inspection questionnaire the home was accommodating 30 residents therefore having 2 vacancies. The home accommodated a total of 4 male residents The registered manager was on duty throughout this inspection in addition the registered provider attended for a short period of time. During this inspection discussions took place with the manager, the registered provider, some members of care staff members and a number of residents. A partial look around the home took place which included a number of bedroom as well as communal areas. The care documents of a number of residents were viewed including care plans, daily notes and risk assessments. Other documents seen included medication records, services records, risk assessments and staffing records. What the service does well: The general atmosphere within Northwick Grange in welcoming, open visiting is encouraged so that residents are able to maintain contact with family and friends. Information is available to potential residents and their representatives prior to a resident moving into the home. Other information is displayed around the home including the results of quality assurance monitoring, access to records and the homes complaints procedure. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 6 An initial care plan is drawn up once somebody moves into the home based upon the homes assessment of care need. Care plans are in place regarding each resident. Residents are able to access healthcare professionals based on individuals care need. Residents were complementary regarding the food provided. One relative wrote upon a comment card issued by the commission the following: ’** not only receives excellent care in practical terms but I am always appreciative of the genuinely caring way it is given and the patience and the cheerfulness of the staff.’ One resident during the inspection described the home as ‘Like home from home.’ Residents spoke highly of staff members; one resident stated that they (referring to the staff) are ‘so good to us – wonderful – not just one, all of them.’ What has improved since the last inspection? What they could do better: The registered provider should consider making the service users guide available in other formats such as large print. Care plans need to contain additional detail to ensure that carers are able to deliver care in a consistent way. Care plans and risk assessments need to be reviewed and up dated following any falls or other incidents within the home. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 7 The communal areas of the home are satisfactory although some signs of wear and tear were noted. Other areas of the home including some bedrooms and toilet facilities are in need of improvement. Further improvements are needed regarding infection control within the home including the provision of hand washing facilities within the laundry. Some health and safety matters were discussed during the inspection and detailed within the main body of this report. Efforts to reduce the high temperature within an area of the home need to continue in order to safeguard residents against extreme heat previously noted. Recruitment procedures need to be improved in order to fully safeguard residents by ensuring that all pre-employment documentation is in place prior to a new employee commencing duty. The number of staff on duty during the afternoon / evening needs to be reviewed especially at times when no kitchen domestic is on duty to ensure that care need are met. 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. Northwick Grange DS0000018666.V334481.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 Northwick Grange DS0000018666.V334481.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): Standard 3. Standard 6 is not applicable Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Potential residents and their representatives are provided with sufficient information to help them make a decision regarding admission to the home. Residents care needs are assessed prior to admission, to ensure that the home can provide the level of care identified. EVIDENCE: A copy of both the Statement of Purpose and Service Users Guide were on display near to the lounge. These documents were not assessed in any detail as part of this visit. It was however noted that they contained sufficient detail to equipment residents and potential residents with information about the home and services provided. The service users guide is not currently available in other formats such as large print. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 10 The signed terms and conditions (contract) regarding a recently admitted resident was reported to be held at head office and therefore not available to the inspector. The file of a recently admitted resident contained an initial assessment. The registered manager had completed the assessment prior to the resident’s admission into the home. The information available to carers was sufficient in detail to enable the completion of an initial care plan entitled ‘residents record’ which was drawn up and date on the day of admission. The registered manager does not currently write to potential residents and or their representatives to confirm that care needs can be met following the initial assessment. Northwick Grange does not offer intermediate care. Northwick Grange DS0000018666.V334481.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): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living within the home receive professional medical input based on individual care needs and the principals of privacy and respect are put into practice. Care plans and risk assessments were not always updated and did not always contain sufficient information to provide staff with the necessary information to ensure consistency in care delivery. Some improvement is necessary to ensure that medication is managed efficiently. EVIDENCE: As part of this inspection a number of residents files were examined. Each one contained a care plan and a number of other documents including risk assessments. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 12 It was noted that one residents care plan contained details regarding a recent chest infection as well as information regarding diabetes and the signs which carers needed to be aware of regarding possible diabetic emergencies. It was stated that two days per month are allocated to up date and review care plans. Residents had signed their own care plans. Although some areas of care need where recorded in sufficient detail the majority were not. Elements of identified care needs require expansion to ensure that carers are delivering care in a consistent style. Information regarding a number of residents who had fallen within the home was gleaned from documents such as accident records and daily notes. Although risk assessments were in place neither these nor care plans were reviewed, evaluated and up dated following each fall. Entries within documents seen showed that residents are supported to access health professionals such as community nurses and opticians. One professional stated upon a comment card returned to the commission that ‘one of Northwick Granges greatest strengths is their communication with both family and other professionals.’ Another professional commented ‘I have always had positive experiences relating to the care at Northwick Grange’ Bedrails with bumpers were seen to be in place in a number of bedrooms to safeguard residents who were assessed as requiring such equipment. At the time of this inspection preparations were in hand, including staff training, to enable staff to change from one medication storage system to another. Previous inspection reports have highlighted a number of shortfalls regarding the management and administration of medication. Subsequent reports have previously evidenced that suitable action is taken however additional shortfalls have then become apparent. As part of this inspection a number of MAR (Medication Administration Record) sheets as well as a number of MDS (Medication Dispensing System) blister packs were viewed. The records held were generally in good order. A copy of guidance issued by The Royal Pharmaceutical Society of Great Britain was available as was a sheet showing staff who have delegated responsibility for administering medication. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 13 Photographs of residents were available and medication was booked into the home. The majority of MAR sheets indicated any known allergies but this was not always the case. It was not always possible to carry out a full medication audit, as some MAR sheets did not match the blister packs. The records of one resident stated that medication was given however corresponding medication was held within the blister pack. The date of opening was not recorded on the boxes of some medication not included within the blister system therefore making a drug audit difficult. An audit of antibiotic medication balanced correctly. Medication was stored in a suitable trolley. The trolley was secured as required, however the location of the trolley gave some cause for concern due to the temperature within the area. The registered manager was aware of this and planned to move the trolley as part of the forthcoming changes to medication systems and practices within the home. The registered manager believed that residents have an improved choice of when to get up and when to go to bed as a result of having additional staff on from 7.00am and having an extra person on duty between 8.00 and 9.00 pm. One resident stated that Northwick Grange was ‘Like home from home.’ Conversations with residents were limited due to varying degrees of dementia type illness. Observations made during the inspection showed that residents were relaxed within the care home integrating well with staff and other residents. Residents seen looked suitably attired taking into account gender issues and weather conditions. Carers consulted were able to give a good verbal account of the care needs of residents who were case tracked, despite the evident gaps within the care planning process. Northwick Grange DS0000018666.V334481.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): Standards 12, 13, 14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Stimulation within the home demonstrated an understanding of the care needs of people with a dementia type illness. Comments regarding meals were favourable but the choice available at lunchtime is limited. EVIDENCE: Open visiting is in place whereby no restrictions exist. No visitors were seen within the home throughout this inspection. Following the previous inspection it was reported that links with the local community were limited, no evidence to suppose anything different was seen during this inspection. Information regarding resident’s access to records is displayed as is information regarding how to contact external advocates. It was evident that residents are able to bring into the care home their own personal possessions. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 15 Religious needs are met by means of ministers visiting from a nearby Church of England once per month. A priest from a local Roman Catholic Church visits weekly to carry out communion. A part time activities coordinator is employed within the home who works 6 hours per week. Information regarding activities is available on a notice board. Each morning the activity is listed as ‘reading newspapers’. It was stated that one national morning paper and the local daily paper are purchased on behalf of residents. Other residents purchase their own copies. Due to the number of papers available the stated activity is therefore limited. Other morning activities generally consist of listening to music or watching television. The inspector viewed a couple of activities taking place including a discussion group and a game of dominoes involving a number of residents. The dominoes used were large and suitable for persons with either a visual impairment or a dementia type illness. The game of dominoes was particularly pleasing to witness due to the level of interaction between residents and staff. It was clear that residents enjoyed the game and the rivalry to win. One resident stated that there are ‘things to do in the afternoon.’ The days menu was displayed within the dining room. Lunch on the first day of this inspection consisted of steak and mushroom pie, mashed potatoes, cauliflower and leaks. Sweet was plum crumble or rice pudding. The previous inspection reported states ‘ A choice was offered to residents regarding the meal as well as the type of drink available.’ Although a choice of sweet was available no choice routinely appears on the menu for the main dish following a recent review and standardisation of menus within the organisation. It was noted that the alternative sweet usually consisted of a milky pudding. Despite the above comments residents appeared to enjoy their lunch and a number of residents consulted stated that the meals are good. The registered manager was confident that residents receive 5 portions of fruit or vegetables a day. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place and staff are currently receiving training related to safeguard adults which supports the rights of residents and the protection of residents from abuse. EVIDENCE: The commission have received no complaints regarding the service provided at Northwick Grange since the last inspection. The registered manager stated upon the pre-inspection questionnaire returned to the commission prior to the inspection that the home had received no complaints; the manager confirmed this statement during the actual inspection. One relative stated upon a comment card returned to the commission that he/she was not aware of the home’s complaints procedure but acknowledged that it is available if ever needed. Another relative answered ‘no’ to the question ‘Are you aware of the home’s complaints procedure?’ A number of professions returned comment cards indicating that they had not received any complaints regarding the service offered at Northwick Grange. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 17 A matrix evidenced that staff have undertaken training regarding the safeguarding of adults against potential abuse. The registered manager has in the past taken any allegation of abuse seriously. A number of staff were consulted during the inspection all of whom stated that they would report any actual or alleged abuse. The previous inspection report noted that the homes policies and procedures regarding safeguarding or the protection of vulnerable adults needed to be up dated. These up dates have not as yet happened. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 24 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Some areas of the home are acceptable while others are in need of repair or refurbishment in order to provide an environment that is homely and safe to live in. Infection control measures have improved to reduce the potential risk of cross infection, these need to continue to safeguard residents. EVIDENCE: Previous inspection reports have highlighted a number of shortfalls regarding the need for refurbishment around a number of areas of the home. Although further improvements are needed improvements were noted during this visit. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 19 The floor in the kitchen has been replaced since the last inspection. Carpeting in some areas of the home needs replacing. Some bedroom doors have suitable locks fitted while others do not. The registered provider continues to intend to fit locks to bedrooms were or when the occupant requested a lock to be fitted. Care plans state if a key is not requested. In order to meet the standard the facility to lock all bedroom doors to meet future needs should be provided. The furniture supplied within the communal areas is of a satisfactory standard, although some chairs within the lounge are showing signs of wear and tear. It was reported that the curtains in the lounge area were recently changed. Bedroom furniture is not in general to such a good standard. In many cases the current occupant owns some of the bedroom furniture within their bedroom. The wardrobe within one bedroom was not secured to the wall to prevent accidental toppling; this should be done to prevent potential injury. Restrictors to prevent accidental or deliberate falling from windows were in place on all those checked above ground floor level with the exception of the manager’s office. Suitable safeguards need to be introduced to ensure that residents do not have access to the unrestricted window. A discussion took place regarding the glazing within the patio windows. The suitability of glazing is detailed in the Workplace (Heath and Safety) Regulations 1992. Guidance issued by the Health and Safety Executive states ‘ serious injuries have occurred when people have fallen through glass windows. It may therefore be necessary to fit suitable safety film (or replace with safety glazing to BS 6262 to glass at or below waist level’. The guidance continues with ‘Glass doors and patio windows must be fitted with toughened or safety glass or covered with a protective film that prevents glass from shattering. They must have a conspicuous mark or feature sufficiently obvious that people will be unlikely to collide with them. When replacement glass is required then reference to BS 6262 should be made.’ The floor of one bedroom has a vinyl covering. The registered manager confirmed that the vinyl covering is necessary. In the event of another resident residing in that room a more suitable floor covering must be fitted. The bedrooms in the ‘flat area’ do not have wash hand facilities within the bedrooms therefore residents need to share the facilities within a bathroom. The entrance area in the flat area contained cat food dishes and other items making the area appear untidy. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 20 The paintwork in this area is damaged and in need of attention. The registered manager has previously stated that Environmental Health officers have not voiced any concern regarding the fact that the flat area is reached by means of entering the kitchen door and passing through a preparation area. A passageway to an exit in this area is used as a smoking area. During the previous inspection the corridor between the dining room and the lounge was particularly warm due to a glass roof. Although a ceiling fan was in place it was stated that serious consideration needed to be given as to how to control extreme temperature levels. It was reported on this occasion that the glass is to be painted over to reflect the suns rays. Liquid soap and paper towels were available within toilets and bathrooms viewed in line with local infection control procedures however a bar of soap was also noted within one toilet. Some of the toilet facilities were functional and could do with improvement. The registered manager has in the past discussed the possibility of introducing antibacterial hand gel for staff to carry upon their person in order to further increase the infection control measures within the home. No offensive odours were noted at any time throughout the inspection. The sluice washing machine was reported to be new since the last inspection. The laundry does not contain a suitable facility for hand washing. Northwick Grange DS0000018666.V334481.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): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The number of staff on duty at certain times needs to be reviewed to ensure that the healthcare and personal care needs of residents can be met. Shortfalls in recruitment procedures can potential place residents at risk. Training takes place to provide staff with the required skills and knowledge to carry out their job. EVIDENCE: Staffing rotas were supplied to the commission prior to the inspection along with the pre inspection questionnaire. The rota indicates the senior member of staff on duty and who is responsible for the administration of medication. The current weeks rota was viewed in greater detail. The rota shows the role in which each member of staff is employed, for some persons who undertake different jobs such as both care and domestic they are named twice. On the day of the first visit to the home two senior carers were on duty in addition to the registered manager and an employee who does some care and some work within the laundry. The rota indicated that four carers and the Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 22 manager were scheduled to be on duty during morning shifts. Three carers cover the afternoon shift. A kitchen domestic is employed however it was noted that the forthcoming weekend was not covered therefore relying on carers, and reducing the availability of carers able to meet care needs. No cleaners are employed at the weekend, therefore relying on carers. A number of residents spoke highly of the staff. One resident remarked that staff are ‘so good to us – wonderful – not just one, all of them.’ Employment records regarding two individuals were seen as part of this inspection both of whom had started work at Northwick Grange since the previous inspection. Some shortfalls in the recruitment process were apparent and need to be addressed in order to fully safeguard people living within the home. Failure to implement a fully robust recruitment procedure can potentially place residents at risk. One member of staff who started work during October 2006 has no CRB (Criminal Records Bureau) disclosure although a PoVA (Protection of Vulnerable Adult) check was in place. The PoVA check was however dated after employment had commenced. Translated references were available. Another employee had commenced work prior to the home having received a second written reference. The first reference was addressed ‘To Whom It May Concern’, this was however followed up by means of a telephone call to check is authenticity. A training matrix was in place, which evidenced that the majority of staff have received mandatory training. Where training up dates are required the matrix highlighted these shortfalls. Staff members recently attended infection control training. The pre-inspection questionnaire and the homes own quality assurance document showed that 45 of staff have achieved a level 2 National Vocational Qualification. Other information indicated that the level achieved was now 50 . As additional staff are currently working towards this qualification therefore it is likely that the 50 level of staff will be exceeded in the near future. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The overall management approach in the home promotes and protects the health, safety and welfare of residents and staff. Some areas related to health and safety need to be improved to ensure the safety of residents and staff at all times. EVIDENCE: Certificates showing the training undertaken by the registered manager were on display. These include the Registered Mangers Award which is a NVQ (National Vocational Qualification) level 4. A certificate following the award of Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 24 ‘Highly Commended in category nursing home carer of the year 1990’ presented to the registered manager prior to her current role by Age Concern was displayed. The Redwood group of homes has a system whereby 6 monthly audits provide feed back from residents, family and others such as doctors. These form the homes Quality Assurance system. The responses are audited and the findings displayed. Comments noted within the document include ‘ Always a friendly atmosphere when we walk in’ and ‘ As visitors we are always made very welcome by what seems to be a very dedicated caring and professional team.’ Other methods of ensuring a full quality assurance programme continue to need to be improved. The registered providers reports following monthly visits were available and viewed as part of this inspection. The home does not offer any system for the safe keeping of resident’s money, therefore residents representatives are invoiced for any expenditure such as hairdressing and private chiropody. The registered manager is aware that the National Minimum Standards state that care staff should receive six formal supervision sessions per year. During this inspection it was evident that the majority of staff have so far received two supervisions during 2007. It was noted that the laundry door had no means of securing it. The fact that easy access to this area could be achieved was of some concern due to the availability of cleaning materials. In addition some pipe work within the laundry was hot to the touch and could potentially scald, the pipes need to be risk assessed and appropriate action taken. A folder entitled ‘Safer Food Better Business’, which is a food safety management document designed by the Food Standards Agency was in place and used effectively. Staff have received training in a range of areas including moving and handling and infection control. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 25 Fire safety checks, which should taken place on a weekly and monthly basis, are taking place. A fire evacuation plan was in place however this did not include a disaster plan. Some staff need an up date in fire safety training. Reference to window restrictors is made earlier within this report. Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 X X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 27 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 (1) Requirement Residents care plans must be reviewed on a monthly basis or more frequently to ensure they are up to date and detail how carers are able to meet identified care needs This requirement replaces similar requirements within the last report. The previous timescales of 02/06/06 not met. This requirement must be met within the new timescales 2. OP7 13 (4) A suitable and up to date falls risk assessment must be maintained in relation to residents individual care needs Previous timescale of 02/06/06 not met - This requirement must be met within the new timescales 30/06/07 Timescale for action 31/07/07 Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 28 3. OP9 13(2) Accurate records must be maintained regarding all aspects of medication administration within the card home to safeguard residents This requirement replaces a similar requirement within the previous report 21/05/07 4. OP19 13 (4) 23 (2) (b) All areas of the home must be kept in good repair and good order. Previous timescale not met – a new and extended timescale is given 31/12/07 5. OP25 23(2)(p) Measures must be taken to safeguard residents against the build up of excessive heat along the ground floor corridor 01/08/07 6. OP27 18 (1) Staffing levels at the home must be reviewed, to ensure service users’ needs are effectively met at all times Previous timescales of 02/06/06 not met – a new and extended timescale is givens 31/08/07 7. OP29 19 Schedule 2 Two written references must be obtained prior to staff commencing duties. Previous timescales of 02/06/06 not met – a new and extended timescale is givens 02/06/07 Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 29 8. OP38 13 (4) Systems for safe storage of cleaning materials need to be robust inorder to safeguard residents. 25/06/07 9. OP38 13 The window in the manager’s 25/06/07 office must be assessed for the risk it presents to the people living within the home and action taken to minimise identified risks 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 OP9 Good Practice Recommendations The registered manager should take suitable action to ensure that controlled medication can be counted without having to empty the contents on to a paper towel. Not assessed as part of this inspection 2. OP18 Although evident that the registered persons have a good knowledge of the action to be taken in relation to reporting matters of either actual or alleged abuse the procedure should be amended to include reference to the CSCI and the adult abuse coordinator. The suitability of toilet facilities within the home should be reviewed Residents should be provided with single action locks on their bedroom doors to provide privacy and means of escape in the event of a fire 3. OP21 4. OP24 Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 30 5. 6. 7. OP24 OP24 OP25 All fatigued items of bedroom furnishing and carpets should be replaced The availability of wash hand basins within ‘the flat’ area should be reviewed. It is strongly recommended that the suitability of the glazing below waist height is assessed and appropriate action takes place to safeguard residents. It is strongly recommended that as further infection control methods staff are issued with anti-bacterial hand gel and wash hand facilities are provided within the laundry. 8. OP26 Northwick Grange DS0000018666.V334481.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Worcester Local Office The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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