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Inspection on 20/09/06 for Pirton Grange Nursing Home

Also see our care home review for Pirton Grange Nursing Home for more information

This inspection was carried out on 20th September 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides 24-hour nurse-led care for predominantly younger adults who possess significant, complex and challenging healthcare needs. Care records could effectively demonstrate the needs of individuals and how those needs should be addressed. Residents interviewed were very complimentary about the home manager, the staff and the quality of care service that was provided.

What has improved since the last inspection?

Care records have improved significantly since the time of the previous inspection along with records and procedures for staff recruitment and selection.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Pirton Grange Nursing Home The Grange Pirton Wadborough Worcestershire WR8 9EF Lead Inspector N Richards Unannounced Inspection 20th September 2006 10:00 Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 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 Pirton Grange Nursing Home DS0000004133.V309556.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 and Care Homes for Adults 18 – 65*. 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. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pirton Grange Nursing Home Address The Grange Pirton Wadborough Worcestershire WR8 9EF 01905 821544 01905 821257 admin@pirtongrange.co.uk 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) Pirton Grange Limited Catherine Yeates Care Home 34 Category(ies) of Physical disability (34), Physical disability over registration, with number 65 years of age (34) of places Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is primarily for people with a physical disability, but may also accommodate people with an associated mental disorder. The home may also accommodate 2 named persons over the age of 65 years whose needs fall within category OP. 19th January 2006 Date of last inspection Brief Description of the Service: Pirton Grange is a period building providing accommodation to a total of 34 residents on the three floors within the home. A passenger lift and a staircase access the floors to the building. The home is situated in the village of Pirton, approximately five miles south of Worcester. It is registered to provide twentyfour hour nurse-led care for residents, and is staffed by registered nurses and care assistants throughout the twenty-four hour period. Weekly fees range from £855.10 through to £1591.31, and includes everything apart from personal clothing. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out over two days on the 20th and 21st September 2006. The inspection totalled 8½ hours and represented the home’s first key inspection for 2006/07. On the days of the inspection, the home was accommodating 34 residents. A full tour of the home was undertaken, residents care records were reviewed, health and safety records were reviewed, staff records were reviewed and some residents and staff were spoken with to establish their views about the home. What the service does well: What has improved since the last inspection? What they could do better: Action could be taken to improve the physical environment of the home. Pirton Grange is an adapted building, and environmental restrictions can create problems for staff and residents. For example, the current central passenger lift is small and is not conducive to free access for mobility-impaired residents who require staff assistance. It is acknowledged that the parent organisation has plans to build an extension to the home, but the current physical environment is in need of review to ensure compliance with the environmental standards specified with the National Minimum Standards (Care Homes for Younger Adults). Please contact the provider for advice of actions taken in response to this Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives with appropriate information and advice to assist them in making their choice about the home. The manager assesses all residents prior to admission to ensure the home can meet the assessed needs of the prospective resident. EVIDENCE: The home produces the Statement of Purpose and the Service User Guide in a format suitable for the residents to understand. For many residents the home is chosen for them by their relatives. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 9 Individual records are kept for each of the residents, and inspection of the records for three residents had fully comprehensive assessment information recorded. Staff members on duty knew about the care needs of the three residents. The registered manager visits and assesses all prospective residents prior to admission to ensure that the home can safely meet their care needs. Pre-admission assessments and visits usually occur in hospital – which is the usual place of residence for most potential residents. The pre-admission assessment then forms the basis of the residents’ care plan. The home offers any prospective resident the opportunity to visit on a trial basis before deciding on a long-term placement at the home. Contracts examined had the option of a settling-in period All residents have a contract on admission to the home. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 (Adults 18-65) and 7, 14 and 33 (Older People) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that residents are consulted regularly on their changing needs and are supported to take risks. EVIDENCE: Three residents’ care plans were reviewed at the time of the inspection. The care records clearly showed that residents and their representatives were being routinely consulted about the care provided. Documentation available showed that risk assessments were taking place, and action was being taken to minimise risk once it had been identified, while promoting, as far as possible Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 11 independence. The home was effectively counterbalancing principles of independence promotion with their responsibility to promote residents’ health and safety. Care records included details about residents’ social activities, outings undertaken, clubs they were attending, and family contacts. The home retains a visual record of all activities that residents have engaged in and have undertaken. Residents spoken to confirm they went out, had contact with their families and were encouraged to pursue their hobbies. Regular meetings were taking place between staff and residents, and their views are valued and actioned wherever possible. Care records are stored securely in the nurses’ office. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 (Adults 18-65) and 10, 12, 13 and 15 (Older People) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 13 Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. Social activities are varied to meet individual resident’s needs. EVIDENCE: Residents’ care records give details of social activities and record each resident’s preferences for activities. The home employs dedicated staff that are responsible for activities and therapies. An Activities Organiser is employed for 40 hours each week, and this provision is based on flexibility and the needs of residents. A reflexologist provides treatment for residents at no additional cost and the home also contracts to provide physiotherapy input. Activities for residents include visits to; local public houses, the cinema, a hydro- pool in Malvern and shopping trips. The staff are committed to ensure that the residents’ outings are undertaken, and give their time to ensure residents’ needs are met. In terms of choice, and how people felt about living in the home, one resident explained that life at the home was more about the home being a home rather than an institution, and she explained how staff have helped to enable rather than disable her by promoting her independence, and enabling her to take responsibility and control over her own decisions and actions. Opportunity was taken to talk to another resident who preferred to keep his own company and spend his time alone in his room. He explained how staff had encouraged him to use a computer and gain internet access to the outside world, and how, since using the internet, he had been increasingly able to shop and make his own purchases online. One person living at the home had been supported to undertake voluntary employment two days each week, but the registered manager explained how the complex medical conditions of many residents served to preclude many people from accessing meaningful employment. The home provides a varied menu to accommodate residents’ likes and dislikes. Feedback from residents was very complementary about the choice, quantity and quality of the food provided. An examination of the menu system confirmed that meals provided were nutritionally balanced, varied and reflective of the choice and preferences of younger people. The registered manager described how some medical conditions such as Huntington’s Disease (HD) presented challenges to nursing staff to ensure that people’s energy intake matched their output i.e. sometimes in the region of 7000 calories a Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 14 day. Care records confirmed that nutritional intake requirements for people with Huntington’s Disease was being effectively met through careful and skilled nursing intervention. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 (Adults 18-65) and 8, 9 and 10 (Older People) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Significant progress has been made on improving arrangements to ensure that the health care needs of residents are identified and met. EVIDENCE: Individual plans of care are available, and progress has been made to ensure that all aspects of health, personal and social care needs are clearly identified and planned for. Plans were detailed, but simple enough to enable care staff to follow the program of care. Significant events in the home had been recorded, daily entries into case records had been made and entries available gave an Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 16 indication of the actual care given. Staff were observed providing care in a sensitive way to the residents. Medication systems were well managed. The home has a good relationship with the home’s general practitioner who undertakes pre-planned visits to the home once a month and more frequently when the need arises, and a clinical consultant visits frequently to review the residents and the medication they are taking. Individuals also have access to a HD consultant based at Evesham Community Hospital, while Speech and Language Therapists also provide advice and support to the home and specialist nurses. Chiropody services are contracted in each week and all residents have freedom of access to NHS (National Health Service) services. The home effectively meets the challenging needs of people with complex healthcare requirements in a positive and sensitive manner. Staff were interviewed and explained that rather than give residents pity, they give people the respect and support they require to partake of as normal a life as possible. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are handled objectively. A vulnerable adults procedure ensures a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a clear simple complaints procedure in place. Since the last inspection the CSCI has received no complaints in respect of the service. The homes complaints records were reviewed and showed that the home was following their complaints procedure. An open, grass-roots approach to complaints resolution is promoted within the home, and staff are eager to resolve concerns informally before they escalate into complaints. All concerns, no matter how small, are addressed by the home, and records show how the home uses the outcomes from complaints and concerns as a learning curve to improve service delivery wherever possible. All staff receive regular training on the protection of vulnerable adults. There have been no issues reported since the last visit. The home has policies and procedures for the management of physical and verbal aggression Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 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. Residents are provided with a warm, clean and comfortable home that is, generally, well maintained and meets their assessed needs. However, the home is an adapted building and, as such, is not purpose-built. This results in the physical environment creating potential problems for people who are very physically dependent. EVIDENCE: Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 19 Pirton Grange is an old, detached property, which has been converted into a care home. The home provides two lounge areas, a small dining room, and a shaft lift to assist residents to access all areas of the home. The home’s manager advised the inspector that the lift operation has presented several problems to staff and residents, and was becoming unreliable. Although records of remedial maintenance action have been recorded, opportunity must be taken to review the effectiveness and reliability of the current passenger lift. Several parts of the home have been redecorated, which has further enhanced the home’s appearance. The physical environment could be further improved through the development and implementation of a structured redecoration program. It is understood that the new owners of the home – “European Wellcare” – have plans to extend the home, but no formal notification has yet been received by the Commission. It is worthwhile noting that, even if the organisation plans to invest through extension, opportunity needs to be taken to enhance the current physical environment in the interests of the current occupants. All the bedrooms have been personalised by the resident to reflect their individual choice. It was noted that one bedroom’s ceiling had fallen-in due to water leakage. An immediate requirement was issued to ascertain the extent of the damage, and the organisation effectively resolved the damage sustained to the bedroom area. The resident was interviewed and appeared quite happy with the service provided. The home stands in large well maintained grounds, and a seating area is available for the residents to use when the weather permits. The garden is easily accessible for residents in wheelchairs. The management and organisation of the maintenance and servicing records was commended. The home’s maintenance operator retains a very good photographic record of work undertaken, and is very committed to providing a positive service to the home. All areas of the home were observed to be clean and tidy, and the management of odours within the home is commended. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and competencies are suitable to ensure that residents’ needs are identified and effectively met. EVIDENCE: There were suitable nursing and care staff on duty to provide care and support for the 33 residents. The home has a stable committed team of staff and use very little agency staff to make up the numbers. In addition to nursing and care staff, there are administration, activity therapists and ancillary staff on duty to support the service provision. The manager reviews the resident’s Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 21 dependency levels and given their unpredictable behaviour the home is staffed appropriately. All staff appeared comfortable in their role and confirmed they enjoyed their work. The residents were also complimentary about the staff and their commitment to their work. The home has provided significant investment and emphasis on staff development and training. Training is identified as a result of the residents’ needs. Three staff files were reviewed at the inspection, and the home has redeveloped their job application forms since the time of the previous inspection. Application forms now provide more information and evidence about training and qualifications and health history. All staff files examined contained two written references that had been taken up prior to applicants commencing employment within the home, and completed enhanced CRB (Criminal Records Bureau) checks had been undertaken. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is clear leadership, guidance and direction to staff to ensure residents receive consistent care, resulting in practices that promote and safeguard the health, safety and welfare of the people using the service. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager is competent and appropriately qualified to manage the service. Staff and residents spoke very highly of her (giving her 9 and 10 out of 10 – one resident described the manager as “like a big sister”), and she has good knowledge and understanding about the residents and their needs. Significant diligence and action has been undertaken to maintain and enhance the quality of the service provided by the home since the time of the previous inspection. Residents clearly expressed their opinion that the home was being run in their best interests – one person said that the home “was like an institution, now it’s like home”, and went on to say that now there was “no bullying, no putting anybody down”. Another resident said “I love this place…staff are brilliant”. Records inspected indicated that regular health and safety checks are carried out including fire safety tests. There are systems in place for risk assessments to ensure the safety of the residents and staff at all times. Regulation 26 reports are completed and forwarded to the CSCI on a regular basis. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 4 38 3 39 3 40 3 41 3 42 3 43 3 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pirton Grange Nursing Home Score 3 4 3 X DS0000004133.V309556.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? 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 YA24 Regulation 13 Requirement Provide and implement an ongoing redecoration program to enhance the home’s appearance. Review the effectiveness and reliability of the current passenger lift. Timescale for action 28/02/07 2. YA24 13 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 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. Pirton Grange Nursing Home DS0000004133.V309556.R01.S.doc Version 5.2 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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