Inspection on 26/06/06 for Romford Grange Nursing Home

This inspection was carried out on 26th June 2006.

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

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

Other inspections for this house

Romford Grange Nursing Home 14/11/07

Romford Grange Nursing Home 19/12/05

Romford Grange Nursing Home 28/10/04

Romford Grange Nursing Home 29/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Romford Grange Nursing Home 144 Collier Row Lane Romford Essex RM5 3DU Lead Inspector Diane Roberts Key Unannounced Inspection 26th June 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Romford Grange Nursing Home DS0000015601.V300217.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. Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Romford Grange Nursing Home Address 144 Collier Row Lane Romford Essex RM5 3DU 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) 01708 755 185 01708 754 454 romfordgrange@highfield.care.com Southern Cross Care Homes Limited Maureen O’Connor Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: Romford Grange is a purpose built care home with nursing situated in a residential area of Romford. It is within walking distance of local shops, and on several bus routes into Romford town centre. The home is registered for 41 older people, who need 24-hour nursing and personal care. There are bedrooms on the ground and upper floor, and a passenger lift that is wheelchair accessible. One of the bedrooms on the upper floor has been converted into a sensory room. There is a large, open plan, lounge and dining area on the ground floor, plus a smaller, similar purpose room, which is also used for meetings. The bedrooms are all single, but do not have ensuite toilets, so each room has a commode. There are bathrooms and toilets on both floors. A small patio area off the main lounge contains raised planted beds, and outdoor seating. Individual care planning is used to identify needs, and how these should be met. A hairdresser and a chiropodist visit on a regular basis. Southern Cross Ltd, which is a large private sector provider operate the home. The current scale of charges is £540.00 to £700.00. Additional costs for items such as hairdressing, chiropody and newspapers etc. Information is made available to prospective service users via a Service Users Guide and Statement of Purpose. Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over seven and a half hours and was carried out as part of the annual inspection programme for this home. The manager was present throughout the inspection The Inspection focused upon all of the key standards and the homes response to the last agenda for action. A partial tour of the premises was undertaken. Evidence was also taken from the Pre Inspection Questionnaire completed by the home and submitted to the CSCI. Five residents, three relatives and six staff were spoken to during the inspection. Seven comment cards were returned from residents/relatives and four were received back from the staff team. What the service does well: What has improved since the last inspection? What they could do better: The home needs to improve upon the assessment of residents’ care needs and ensure that they are attending to all their needs, especially in relation to their mental health and social wellbeing. Some aspects of residents’ healthcare could be improved upon and there are still some minor shortfalls in relation to medication. Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 6 The bathrooms and toilets at the home need upgrading/redecoration and reflect poorly on the home. The garden facilities at the home are also poor. The quality assurance programme at the home needs developing so residents’ and relatives’ views are taken into account on a regular basis. 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. Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 and 3. Standard 6 is not applicable to this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. Whilst contracts are in place not all residents/relatives are aware of these or have a copy. Prospective residents are properly assessed prior to admission to the home, which ensures the home can meet their current needs, but the assessment process, once in the home, demonstrates shortfalls. EVIDENCE: The home has a Statement of Purpose and Service Users’ Guide. These documents were seen to meet the required standard but the home does need to ensure that residents and interested parties are clear that they are able to have full access to a copy of the last inspection report as well as just a very Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 9 short summary that the home has listed. A copy of the last inspection report was available in the home. The registered persons also need to ensure that the service is adhering to the information in the Service Users’ Guide, for example, ‘the home has landscaped lawns and flower beds to the rear of the home with easy access’ and ‘that residents are given satisfaction questionnaires on a yearly basis’. Please refer to Standard 19 and Standard 33 of this report. Residents and relatives spoken to on the day of the inspection said that they had received a Service Users’ Guide for information. Residents who also provided written comments said that they had enough information about the home prior to accepting a placement. Residents and relatives are always invited to visit the home before admission. One of the service user’s case tracked said she had visited the home before deciding to move there. She stated that she was invited to stay for lunch and was made to feel welcome by the staff and was able to spend time with the other residents and talked to them about what it was like living there. Other relatives said that they felt well informed and that the manager had plenty of time for them at a time when they needed it. From records, it is clear that satisfactory contracts are in place, which outline the terms and conditions of residence. At least half the residents who commented stated that they did not have a contract and this needs to be addressed, with residents and relatives being unsure about the terms and conditions of residence and whether a contract is in place at all. There is a satisfactory pre admission assessment tool in place and the manager tends to undertake the majority of these assessments. Completed pre -admission assessments were seen to be comprehensive with detailed and individualised information. Following admission a full physical and social assessment is undertaken, which forms the basis of the care plan. The home needs to ensure that all the information from the pre-admission assessment is utilised, where appropriate. It was noted that care needs identified and still active were then lost in the following assessment. The home also needs to develop its assessment and acknowledgement of residents’ psychological state on admission to the home and transfer this to the subsequent care plan. Significant care needs relating to this were noted to be ‘lost’ in the assessment process. This must be available to all staff to ensure that they can meet the social, emotional and care needs of new residents. Social assessments were also noted to contain limited information. Relatives spoken to confirmed that specialist equipment was ready and waiting for when their relative arrived at the home. Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 10 Romford Grange Nursing Home DS0000015601.V300217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have individual plans of care in place but shortfalls are evident that need to be addressed. Residents’ healthcare needs are generally met but shortfalls and inconstancies were noted. Medication systems are generally sound but shortfalls were noted in specific areas. The privacy and dignity of residents is taken into account. EVIDENCE: There is a care planning system in place introduced by Southern Cross This is a good system, which gives guidance to staff on each record sheet pointing them in the right direction. Every resident has a care plan in place. Care plans that were in place were comprehensive, with good individual detail, but from observation and records, not all the care needs identified have a care plan. In Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 12 particular psychological and social care plans were limited or not in place but also ones relating to physical care needs were missing. Daily notes are maintained and these are linked to numbered care plans. These primarily relate to physical care provided and do not actively comment on the residents wellbeing as a whole. Weekly progress reports are written and these were seen to report on the resident as a whole giving a better outline of their overall wellbeing. Care assistants working in the home write these. Relatives report good communication from the home with regard to issues around the care of their relatives but they do not have an active input with the care plan and from discussion, neither do the residents. This needs to be reviewed. Care plans in place contain evidence of regular review but it is questionable as to how meaningful these are when there are care needs with no care plan in place. Staff spoken to state that the nurses and the senior carers keep them informed regarding any changes to residents care plans. The staff spoken to be able to describe the plans for the residents whose care was case tracked. This shows that residents care needs would generally be met. As part of the care planning process, the home uses a variety of risk assessments. These were seen to cover the required range of risk areas and were completed appropriately, linked to care plans and showed evidence of regular review. The home has a good supply of specialist beds and the manager reports that the provider is very good at supplying these pieces of equipment when needed. At the time of the inspection the home were caring for residents with pressure sores, some of which were hospital acquired and some of which are acquired in the home. Residents noted to have a high risk of pressure sores were seen to have the appropriate equipment in place. The home needs to investigate why residents have developed pressure sores, with a view to reducing risks in future. Some care records showed that staff were applying creams such as ‘sudocrem’ to pressure areas at risk. No rational was found in the records for this approach and the manager should review this in line with current clinical guidance. Wound management and the associated record keeping need to improve. Records showed that residents were receiving wound care and having dressings applied but there was no care plan in place and limited monitoring of the wound. This needs to be addressed. Some wound management care plans Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 13 were in place and these were seen to be satisfactory and linked to the nutritional needs of residents. The wound management records relating to these care plans were generally sound but staff need to record the wound size regularly rather than putting ‘its decreasing’. The amount of information given by nursing staff on the state of the wound could increase and consideration should be given to using photographs. Records show good evidence of liaison with other healthcare professionals such as dietician etc. and their input was evident in the care plans. Records show that residents see the GP in a timely manner and they themselves commented that they receive the medical support that they needed. Evidence was also available that the community dentist visits the home, as does the chiropodist. The frequency of the chiropody visits should be reviewed to ensure that all residents are receiving an appropriate service as some records showed that residents had not been seen for 4 months. A healthcare professional visiting the home states that she is always made welcome and that the staff know the residents well and finds the care planning at the home helpful and generally up to date. The registered persons need to review the assessments for continence, as these were not evident in all the required care records. The providers are also purchasing only one type of pad for every resident with such care needs. This does not show an individualised approach to the promotion of continence. Residents are weighed on admission and then monthly. However, upon further case tracking the inspectors noted that this was not consistently practised for all the residents. This needs to be addressed The medication system at the home was inspected. The home uses a nomad system but plans are in place to over to an MDS system soon. New medication trolleys are on order to cope with this change. New medications are delivered weekly. The night staff check in the medications at weekends. This system was seen to be generally sound but needs to tighten up on recording medicines that are being carried over from one week to the next. The home has a disposal system in place and maintains records of such. Stock control needs tightening up in this home. Dates of opening are needed on boxes and bottles as no dates give a limited audit trail. Old liquid medications were noted in the trolley from June 2005 for a resident no longer in the home. This needs to be addressed. Some prescriptions need review as medications are being changed from the i.e. one tablet being given instead of two and this had been in place some time. The MAR sheets were generally well recorded but did show quite a few hand written prescriptions. Efforts should be made to reduce these and those written should be neat and clear to read. The staff nurse spoken to confirms that reviews are done on an ‘as and when’ basis with many GP’s visiting the Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 14 home. Consideration should be given to adopting a more formal approach to reviews. Staff were observed to ensure that residents’ privacy and dignity were maintained when providing personal care. This was confirmed by them in discussions and when speaking to residents in the home. All the residents are spoken to state that the staff are very good, caring and look after them well. One resident said, “The staff are very good, I cant wish for better”. Visitors spoken to confirmed that staff are patient and kind when interacting with the residents. Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities programme at the home generally meets the current needs of residents. Contact with visitors and the local community is satisfactory. Residents have a level of choice and control over their lives. The meals service at the home is satisfactory. EVIDENCE: There is an activity program in place and a dedicated activities officer who works at the home. He was not available to discuss the program on the day of the inspection. Residents and relatives spoken to confirm that a variety of activities are on offer both within the home and day trips are planned outside during fine weather. Photographs were seen of outings that have already taken place and two residents spoken to say they really enjoy the trips out. One relative spoken to stated that staff often sit with the residents and play games with them or sit and chat to them. The inspector observed this on the Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 16 day of the inspection. Other entertainers including musicians are invited to the home to play old-time songs, which are thoroughly enjoyed by the residents. Throughout the morning of this visit residents were seen occupying themselves by watching television, reading or sleeping, as the activities coordinator was not present. Some residents had visitors and they were seen sitting in the lounges or in the bedrooms chatting to their relatives and friends. Visitors are spoken to say that they are encouraged to come and see their relative or friend and are always made to feel welcome. One visitor said that “ the staff are very good and people often come and talk to her and her mother.” Residents spoken to stated that they had choice within the routines of the home with regard to going to bed, getting up etc. etc. They said that the staff are quite flexible, although there has been an issue regarding where residents sit at mealtimes, with the staff wanting residents to sit at the dining table with many residents wanting to eat at small tables in front of their easy chairs. This has resulted in residents being sat for long times in wheelchairs rather than easy chairs in order for residents to be sat at the table quickly. This needs to be reviewed to ensure that all residents are happy with the current mealtime arrangements. The dining area is large and residents were seen having their lunches here with many choosing to sit in the lounge or in their bedrooms for lunch. Residents generally confirmed that the food was good and they have a choice of food at mealtimes. The visitor spoken to stated that, “ I have had a lunch here, the food is very good.” On discussion, residents also confirmed that the chef does come out to talk to them about the food and whether they have enjoyed a particular meal, as well as encouraging residents to mobilize, where possible. However one resident stated that she would like to have cultural meals of her choice provided sometimes and that she does not like all the food provided. During case tracking the inspector noted that there was no reference made to her particular dietary needs relating to her cultural background. The manager stated that she would discuss this with the individual concerned and ensure that a variety of meals of her choice are provided. The menus were seen to be very nutritionally balanced. Romford Grange Nursing Home DS0000015601.V300217.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints system in place, which ensures that people’ concerns would be listened to. The home has systems in place, which help to ensure that residents are protected from abuse. EVIDENCE: The home has a clear complaints procedure, which is displayed around the home and is available in the Service User Guide. Both residents and relatives say that the manager is often available to them and that they are clear how to make a complaint or raise a concern. From discussion and comment, it is clear that residents in the home are comfortable with raising any concerns and are happy to speak their minds on anything that is an issue for them. The documentation was reviewed and a complaint log is kept. There is evidence that the majority of complaints are minor and that manager lists all levels of concern, which shows good reporting. Records show that concerns are dealt with promptly and dates are noted. No written letters of concern or complaint have been received by the home; all have been raised verbally with the manager. The home has an up to date adult protection policy and procedure in place. This includes local guidance. Training records show that the home has provided up to date training for all its staff with regard to adult protection. Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 18 Romford Grange Nursing Home DS0000015601.V300217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained but work is needed in some areas. The home is generally clean but attention to detail is needed. EVIDENCE: A partial tour of the home was undertaken. The home was seen to be generally in good decorative order. The main areas of the home that require work are the bathrooms and toilets which have been in place since 1991 and look very tired. These reflect poorly on the home. One bathroom has a new suite on order and will be refurbished – including the floors. Furniture throughout the home was seen to be in a satisfactory condition. Recently the proprietors have been painting bedrooms, replacing carpets and replacing worn vanity units. The home employs a maintenance man who works 30 hours a week. Basic records are maintained but they do not give dates of problems/works identified Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 20 and dates of completion. The maintenance man checks the hot water temperatures in the home and keeps records. Records also show that he checks and maintains wheelchairs. Fire safety records in the home were checked and found to be satisfactory apart from the fire alarm maintenance certificate being recently out of date. The facilities manager for the company has completed a full fire risk assessment and the manager reports that the local fire officer is satisfied with this. The home has a sensory room which is obviously unused and possibly of limited value in this home. At the time of the inspection it was being utilised as a pad and equipment store. This needs to be reviewed as it is referred to in the Service Users’ Guide, as a service available to residents. There is a large seating area to the side of the home adjacent to the driveway and a garden to the rear. The garden at the rear is unkempt and would not be an attractive place to sit. Also clinical waste bins are also stored in this area along with old equipment for disposal. Access to the lawn area is limited. This area needs review and the proprietors should be mindful of the information provided in the Service Users’ Guide. Raised beds to the side of the home are also in need of maintenance. The home was seen to be generally clean and odour free. Some parts of the home need a deep clean and this specifically relates to the bathrooms and toilets. The home has infection control polices and procedures in place. These were seen to be very basic and just covering universal precautions. These require review to include information on the notification of diseases, contacting local infection control teams, outbreak management, cleaning of equipment etc. The registered persons should ensure that staff receive training in current infection control practices. Romford Grange Nursing Home DS0000015601.V300217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and mix of staff at the home meet the residents’ needs. Training provide in the home is generally sound but a formal plan could improve this further. Residents are generally protected by the homes recruitment policies and procedures but minor shortfalls were noted. Staff are trained to do carry out their roles and responsibilities. EVIDENCE: Staffing levels in the home were discussed and staff rotas inspected. At the current time, because resident numbers have dropped, there are 2 nurses and 5 carers on duty during the day. One nurse and three carers are provided at night. There are six 6 carers when the home is full. Staff are deployed to three resident groups with two staff on two and one on her own with lower number of people. Nursing staff float and are available to help when she needed. The rotas show that these levels are maintained with minimal agency use and the home using a bank of their own staff. Staff spoken to are happy working at the home and enjoy coming into work as they feel the home has a good atmosphere. The home has a stable staff team. Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 22 The home employs appropriate ancillary staff to support the work of the home and this includes weekend laundry and domestic cover. The inspector was informed that there is a good level of training provided and that there is a list of training available on the notice boards for staff to enrol on. All the staff are expected to attend training on a rolling basis. Staff stated that they have done specialist training courses through external trainers as well as senior staff internally providing the training. Staff files showed that they have done training in essential areas, such as food hygiene, health and safety, and adult protection, NVQ level 2, catheter care, first aid, diabetes care and in continence management. Records show that the provider has good compliance levels with statutory training such as manual handling, fire and health and safety. Records show that over 50 of the care staff in the home have been trained to NVQ level 2 and above. Some training records were available on the individual staff files however this information needs to be better collated, so that the manager can gauge the level of skill within the home, where the shortfalls may be and target training in a way which equips staff to provide good quality care in order to meet the needs of the residents. The induction record for one newly appointed member of staff was not available. The inspector was informed that the carer keeps this record until it is required. The manager is required to provide the inspector with a template of the induction record. Four staff files were examined. The inspector noted that the organisation’s recruitment procedure is followed. However it was difficult to easily access information from the staff files due to the files not being sufficiently well organised. A large number of loose-leaf papers were kept in the all files examined. Discussion took place with the manager regarding the requirement to verify references. Of the four files examined, three files did not contain a photograph of the member of staff which is required as part of regulation. The Administration officer was provided with a pro-forma regarding staff information, which all care homes are required to keep. Romford Grange Nursing Home DS0000015601.V300217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager is experienced and has the skills to run the home. The quality assurance systems in the home need to be developed further. Systems for safeguarding residents’ monies are in place. The staff supervision system in the home needs to be developed. The correct policies and procedures need to be made available in the home. The health and safety of residents and staff is promoted. EVIDENCE: Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 24 The manager has worked at the home for many years. Staff spoken to state that they received a good level of support from the manager and that she is approachable and they can go to see her at any time. They also said that the manager was open to ideas to improve services. From discussion, the manager has an open approach with the CSCI and is keen to address any issues raised. Southern Cross has an audit system in place whereby monthly audit takes place, which the manager completes. Alternate months, the regional manager completes the audit. This covers a range of subject areas such as medication, accidents etc. Other audit sheets are also submitted to head office on pressure sores etc. Whilst these audit systems are acceptable, the manager had limited evidence of feedback and consultation with residents and relatives. The home has a feedback questionnaire available for use but the manager could only produce five of these completed in March 2006. There is no formal approach to this aspect of the homes quality assurance programme and no analysis of the questionnaires completed. The forms completed showed that residents/relatives had mixed views about the home and services provided but as there was such a small sample it was difficult to assess the overall response. The home needs to address this. The home has policies and procedures in place for the safe handling of residents’ monies. Records and accounts were checked at random and found to be in order with the appropriate receipts etc. seen, all in order. A non-interest making bank account is in place and the records account for all monies in the account. The administrator reports that Southern Cross are looking to open interest accruing accounts for residents. Staff spoken to confirm that there is a supervision system in place, with senior staff supervising the level below them. On inspection there was limited written evidence to confirm this, and only three supervision records for members of staff were available to the inspector. This needs to be addressed. All the staff confirmed that they have staff meetings amongst their particular groups i.e. senior carer meetings, care assistants meetings and nurses meetings and relevant information is available to the staff group via the managers. Minutes were available for inspection, which showed that a wide range of subjects are covered. Despite Southern Cross being owners of this home since September 2005, the manager reports that the home is still using the previous proprietor’s policies and procedures. This has been a previous agenda item and needs to be addressed. There is an up to date health and safety policy in place. The home does not have any safe working practice risk assessments in place for the home. The kitchen has some food related risk assessments and COSHH data sheets are available. This needs to be developed and was discussed with the manager. Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 25 Training records show that the organisation has good compliance with statutory staff training including fire safety and manual handling. Accident records were inspected and were found to contain detailed information. Occasionally photographs are taken and this was confirmed following a discussion with a resident. Good records of minor incidents are recorded and there is evidence of follow up and awareness by the manager. Records also show appropriate GP referral and relative contact. Romford Grange Nursing Home DS0000015601.V300217.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 3 2 2 X X N/A 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 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 2 Romford Grange Nursing Home DS0000015601.V300217.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 OP1 Regulation 4,5, and 6. Requirement The registered person must ensure that the information provided in the Statement of Purpose and Service User Guide accurately reflects the service provided by the home. The registered person must ensure that information from the pre – admission assessment of residents is then used in their subsequent care plan, where appropriate. The registered person must ensure that all identified care needs have a care plan in place and that where possible residents or their representatives are involved in the care planning process. The registered person must ensure that residents’ healthcare needs are addressed in relation to the prevention of pressure sores, wound management, weight monitoring, the promotion of continence and chiropody. The registered person must DS0000015601.V300217.R01.S.doc Timescale for action 31/08/06 2 OP3 14/15 31/08/06 3 OP7 15 14/09/06 4 OP8 12 and 13 14/09/06 3. OP9 13 31/08/06 Page 28 Romford Grange Nursing Home Version 5.2 ensure the safe handling and administration of medication in relation to the checking in and disposal of medications and dating for audit purposes. 4. OP14 12 The registered person must ensure that all residents are happy with the arrangements for mealtimes at the home. The registered person must ensure that the communal bathrooms and toilets in the home are in good decorative order and in working condition. The registered person must ensure that the gardens are maintained in good order for residents to enjoy. The registered person must take adequate precautions against the risk of fire – with regard to maintaining the fire alarm system. The registered person must ensure that the home is kept clean and that staff have up to date infection control policies, procedures and training. The registered person must ensure that all the required documentation is stored in the staff files – with reference to photographs. The registered person must develop the quality assurance programme for the home to regularly take in the views of residents, relatives and other stakeholders in the home. The registered person must develop the staff supervision programme in order to provide evidence of supervision. The registered person must ensure that all policies and procedures needed to run the DS0000015601.V300217.R01.S.doc 31/08/06 5. OP19 23 14/09/06 6 OP19 23 31/08/06 7 OP19 23 31/08/06 8 OP26 16 31/08/06 6. OP29 7,9 and 19 31/08/06 7 OP33 24 14/09/06 8 OP36 18 14/09/06 9. OP37 12 & 13 31/08/06 Romford Grange Nursing Home Version 5.2 Page 29 10 OP38 13 home are those of the new owners. This is a repeat requirement. The registered person must ensure as far as possible the health and safety or residents and staff and undertake safe working practice risk assessments. 14/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP1 OP2 OP9 OP19 OP28 Good Practice Recommendations The registered person should ensure that via the Service Users Guide, residents are sure they can access a full copy of the last inspection report. The registered person should ensure that each resident has a copy of his or her statement of terms and conditions/contract with the home. The registered person should formalise the approach to residents’ medication reviews. The registered person should ensure that the maintenance records are dated to evidence that work has been carried out in a timely manner. The registered person should review how they hold training records in order to help them formalise a training plan for the home. Romford Grange Nursing Home DS0000015601.V300217.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Romford Grange Nursing Home DS0000015601.V300217.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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