Inspection on 10/05/06 for St Peters Grange

This inspection was carried out on 10th May 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 but made no statutory requirements on the home.

Other inspections for this house

St Peters Grange 24/07/07

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE St Peters Grange 24 Upper Maze Hill St Leonards-on-sea East Sussex TN38 0LA Lead Inspector Jason Denny Unannounced Inspection 10th May 2006 10:20 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 St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 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. St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Peters Grange Address 24 Upper Maze Hill St Leonards-on-sea East Sussex TN38 0LA 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) 01424 423427 Care Anytime Limited Mr Michael Patrick Crotty Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44), Physical disability over 65 years of age of places (15) St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is fortyfour (44) Service users must be older people aged sixty-five (65) years or over on admission Up to fifteen (15) older people with physical disabilities may be accommodated within the total number of forty-four (44) January 24, 2006 Date of last inspection Brief Description of the Service: St Peters Grange is a large Victorian building in a residential area of St Leonards-on-Sea approximately half a mile from the seafront and town centre. The home is close to local transport links. The home is located on three floors of the building with a passenger lift to all floors. The fabric of the home is bright and welcoming to visitors, substantial work has recently been carried out on the environment of the home since a change of ownership. This work has included new bathrooms and redecorated rooms with a rolling programme of renewal and maintenance in place. The home has secluded and well maintained gardens, which are occasionally used by residents. The garden represents a pleasant view for rear facing bedrooms. The home does not currently have its own vehicle although it loans a mini-bus for monthly summer outings. The home is registered to provide care for up to 44 people, up to 15 of which can have physical disability, and offers a limited number of respite places based on assessment. The home is currently not exceeding 34 people in number. The range of fees charged ranges from the Social services basic price of £322.40 to £400 per week. The latest Inspection report is sent out to any enquirer who expresses an interest in the home. A copy of the report is kept on display in the reception area of the home with copy obtainable via the manager. In March 2006 St Peters Grange moved in to the ownership of a company called Care Anytime after a successful registration process with the Commission. Care Anytime run by Mr Amin and V. Patel successfully owns and manages two other care homes, Nursing and learning disability respectively, within the South East. St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced key Inspection, which included a visit to the home which took place between 9.20am and 2.20pm on 10 May 06. This inspection focused on the compatibility of the Resident group, how care is planned and delivered, lifestyles, the environment, staffing, management of the home, and how concerns are dealt with. During this inspection process a number of relatives and social workers have been spoken with along with the overseeing organisation. Survey [Comment] cards were sent to Residents prior to the visit. The focus of the inspection was seeing if some long standing requirements such as staff training and supervisions had been met, along with looking at how respite users are being cared for. Five Resident’s were looked at in detail including new Residents, and two respite users. How the home records and meets different [diverse] needs was also explored. The inspector’s spoke with 9 of the 27 Residents and observed others .Care records for 5 Residents along with health and medication needs were examined. Discussions with management looked at training plans, the issuing of contracts, visits by the new owners of the home, and how care records can be improved. The inspector toured communal areas along with bedrooms. Meal arrangements were examined. A record of complaints was inspected. Staffing was looked at along with the homes management, including measures to ensure quality for Residents.. Two outcome areas are Good, Four are Adequate [ok] and one area is Poor What the service does well: The manager, his deputy and most staff have worked in the home for a number of years, which has provided continuity of care. Routines are flexible to meet resident’s different [diverse] needs. Resident’s benefit from having well equipped rooms, with toilet en-suite facilities. Accommodation is spacious and there is a choice of lounges and well-maintained gardens. The home continues to have enough staff on duty who were described by all Residents as “very good” at their job. A respite user described how she was pleased to keep coming back to the home and enjoying the social contact and activities. An established resident stated how much things had improved in recent years such as the food, the environment, staffing, and activities, and especially cleanliness of the home. The home has a dedicated activities coordinator. Staff were observed to be attentive and skilled at meeting residents needs. The home is good at maintaining a clean and fresh environment. The home ensures the recruitment of suitable people. The home [with one exception] supplies prospective new residents with a good level of information before they make a decision to move in. The home now ensures that before admitting any prospective new resident they first assess them. The home acts quickly when St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 6 they can longer meet care needs. The home surveys residents and families when respite stays come to an end in order to assist further improvements What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 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 St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 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): 2, & 3. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The home needs to demonstrate transparency in relation to contracts held between the service and the resident, by keeping a copy in the home, which is signed and agreed. Assessment information on all Residents including respite users needs to be available in the home and kept up to date. EVIDENCE: Contracts for new residents and respite users over the last 3 years were again, not found to be held in the home. The previous owner who was not based in the home was described as retaining these contracts off-site. The new owners of the home were found to have just sent the manager blank copies to circulate to all Residents for agreement and signature. The inspector was therefore unable to see if the contracts had been agreed had involved all necessary people such as residents, and met the standard, such as showing what fees are being charged and for what. Fees are said to range from St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 9 £322.40 to 400 for larger rooms. Residents who were spoken with raised no issues in relation to money or their contractual terms and conditions. The manager explained that he is has developed a welcome pack and for new residents gives them a sample copy of a contact Residents who moved in before 2003 and those now moving in, have gone through a normal process in relation to agreeing contracts such as fees and room to be occupied. The manager stated that all contracts should be agreed and signed over the next two months. The Inspector look at care information in relation to the newest respite users. In one case there was no evidence of a written pre-assessment having been done by the home prior to admittance. Information consisted in one case of a social services I page contact sheet which was out of date as confirmed by the manager and contained 5 lines describing health issues. There was no careplan or information on how to meet needs. Daily notes were detailed and indicated issues around front door security as the person was observed on moving in to want to leave the home unnoticed. This information was not in any plan of care or care assessment. Staff confirmed that there was no reference information to show how to meet needs in practice. Another respite user who has regularly used the home for respite every 8 weeks for the last 3 years was found to have an assessment completed by the previous manager in 2003, which had not been updated or reassessed. The person had a social services contact sheet with a few lines describing health issues. The manager has improved the home’s practice over the last two years by insisting that all prospective new residents need to be assessed before being admitted including respite users. The manager was reminded that consistent written records need to maintained along with a plan of care to show how needs will be met, with this available to all staff. The manager has also met with the contracts unit to improve the process relating to the admittance of respite users. Social services contracts department confirmed to the inspector following the inspection visit that there is no current issues with permanent long- term residents placed in the home and that needs were being met. However, although there had been some improvement, some respite users have declined to return to the home. Contracts have recommended as part of their review that the home improve care planning for respite users [contract for 6 beds]. The manager and the contracts department were found to be agreeing on further reasonable improvements. The two respite users at the time of the inspection, who were spoken with, indicated that they were pleased with the home with one stating that it was “my fifth time now in the home” and enjoyed the social contact and food. The other respite user has been receiving respite periodically for the last 3 years and looks forward to returning. St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 10 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, & 10. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. All Respite users need to have a care-plan. Although care-plans are improving more specific guidance is needed based on the individual needs. Health needs are promptly met and better recorded, along with improved medication arrangements. Residents are pleased with the care they receive EVIDENCE: The Inspector attempted to sample 5 Care-plans, 2 of which being current respite users. One of these respite users was found not have any plan of care. The other respite user had a briefer plan than permanent residents with this not having been reviewed since 2003 and lacking information about how needs will be met in practice. Both Residents had daily notes, which indicated how certain issues were being identified such as door security. Staff spoken with indicated that although they are given verbal guidance in staff meetings when a respite user comes into the home, there is not a written care-plan to refer to. Despite the risks with these practices there no evidence to show that had affected outcomes for the two respite users partly because they have low, nonSt Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 11 complex needs as confirmed by the manager. The manager showed that the social service contact sheet information is left on the office desk for staff to look at when respite users return to the home but as previously stated [see standard 3] this information is too brief. Care plans were looked at for three permanent residents all of whom were spoken with during the inspection. The plans contained guidance about how to actually meet identified need and what support is required in most instances. All plans indicated whether Resident’s need assistance with a bath but not what residents could do for themselves. The plans contained some information on choices such as room key and how the resident wants to store valuables. The home was advised to record all choices which the individual can make, along with the strengths of the individual. Overall the plans have improved since the last inspection. Plans are now regularly reviewed generally on a monthly basis with slightly more detail in these reviews. The management of the home is looking at ways of involving staff more in the process and accessing relevant training so that plans reflect the full range of different [diverse] needs. Comment cards and questionnaires maintained in the home filled in by relatives all indicated satisfaction with the care being provided to residents. All residents spoken with commented on the prompt attention they receive from staff, one stated “this home is King [compared with the last home she stayed in] I think they [the staff] are marvellous”. A newer resident stated, “this is my first experience of care and I am satisfied” The inspector looked at medication stocks, record keeping, training records at the last inspection which was found to be sound. Staff were again observed dispensing medication in a way which respected residents preferences. Medication was observed to be transported around the home on a trolley as opposed to on a tray as seen at the last inspection. This has improved security and record keeping preventing the risk of dropping or confusing medication. Staff confirmed that only trained people dispense medication. Some residents have their preference to self-medicate respected subject to an agreed risk assessment. A resident’s concern about being able to selfcatheterize has been resolved as seen in records and discussions following a number of GP visits and consultations resulting in the resident confirming that they no longer need to use the equipment. Health information was now found to be documented in the care-plan. St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 12 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, & 15. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from varied and regular provision of popular stimulating activities. Residents are encouraged to be involved in the running of the home and have visitors at flexible times. Food is good, varied, and popular with residents. EVIDENCE: The home provides a range of appropriate activities, which continues to improve in the opinion of residents and based on records and schedules examined. Over the last year the manager has appointed a dedicated activity co-ordinator and introduced Saturday film mornings on a 42-inch plasma TV. A resident who has lived in the home for a number of years stated that last summer she had more outings [3] than she had ever had. The introduction of sherry mornings on Tuesdays, exercise classes on Mondays and quizzes on Thursdays along with Bingo twice a week is popular with residents spoken with. Those who do not attend for health reasons or personal choice are aware of their existence. The bingo session on the day of the inspection was found to be well attended . Resident’s views are collected twice a year through questionnaires and at weekly sherry mornings, which are well attended. One of St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 13 the 9 residents spoken with, indicated that she would like to go out shopping more. The manager indicated that this had recently resumed following a leg injury and that friends take her out at least weekly with the home looking a rota system of providing occasional 1:1 support if necessary. Visitors to the home have previously confirmed the flexibility afforded to them in relation to their visits. Residents confirmed satisfaction with these arrangements. The home was found to have a clear written visitors policy. Decisions such as the choice of a bedroom key are carefully recorded in careplans along with activities, dietary preferences, and financial management. A meal was seen being served to residents which was, well cooked, and healthy. Menus contain a main scheduled meal with alternatives offered depending on the diverse needs of residents with individualised diets for some residents based on their choices and needs such as those who are vegetarians There is also a choice of deserts and suppers, which are both hot and cold. All residents spoken with including new residents some of whom prefer meals in their rooms stated that food was good and is served at the right temperature, with an alternative always offered. The cook regaulry consults with Resident’s as to their views. St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 14 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, & 18. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home is conducted in an open manner with residents and relatives confident and knowledgeable about how to raise concerns. The management team are still awaiting the training recommended in the independent investigation carried out last year. A number of measures are in place to protect Residents from harm such as well-trained and suitable staff. EVIDENCE: The complaints procedure is clearly displayed in the home’s reception area. The home now holds a full record of complaints and concerns made within one file. Since the home has insisted that all respite users are assessed before moving into the home, there has been a reduction in reported concerns. All respite users and their relatives spoken with described the home as good. Complaints management Training for the manager and his deputy along with senior staff is currently being explored and is requirement dating back to two inspections again following the outcome of a complaint investigation carried out by an independent human resource specialist on behalf of the home’s owner, along with involvement of the Commission. [This is explained in more detail in the Inspection report 11/08/05]. No formal complaints have been raised over the last year. A concern from a respite user last year, about bedroom cleanliness explored immediately by the St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 15 home was found not to be upheld. This was seen in records and in the questionnaire filled in by the person concerned, who had also raised the matter with the Commission and who decided not to raise the matter as a formal complaint. All residents spoken with indicated that they know how to raise concerns and all indicated satisfaction with their rooms along with the cleanliness of the home. The home has reviewed its adult protection policy over the last year. This has resulted in an improved step-by-step policy, which highlights the key points and necessary information. This policy is now signed by all staff who also receive their own copy of the policy and procedure. Staff who spoke with the Inspector again showed a full understanding of how to both identify and report alleged abuse. The manager stated that further training was planned during the rest of the year including he and his deputy going on Protection Of Vulnerable Adults training which has previously been delayed by the training provider. The manager showed evidence that he and key senior staff were booked on complaints training on July 4, employment matters training May 16 and adult protection and Protection of Vulnerable Persons training May 24 and 31. The manager was asked to confirm completion of all this training by September 10, 2006. St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 16 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, 24, & 26. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home was found to be fresh, clean, warm, and homely. Bedrooms are attractive, popular with Residents, and well maintained Infection control practices have improved. EVIDENCE: The inspector found a clean home with full schedules in place including daily cleaning staff. All communal toilets had soap dispensers and no bars of soap. The only bedrooms looked at where of these residents who met with the Inspector. All of these bedrooms were found to be in order and benefit from en-suite toilets. All residents spoken with indicated satisfaction with the facilities. A slight odour was noted at the last inspection along the first floor corridor linked to the staff smoking room was found to have been removed with effective procedures in place. All residents spoken with are pleased with the cleanliness of the home as confirmed in questionnaires completed by relatives and visitors, which the home maintains. St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 17 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, & 30. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Tight recruitment procedures are followed to ensure only suitable staff are employed, who are deployed in suitable numbers to meet Resident’s needs. Staff training needs major attention as very few are sufficiently qualified. EVIDENCE: The home is significantly below the target in relation to NVQ trained staff. The manager again provided written evidence of 2 staff that have a NVQ 2 qualification with 2 on the course with 2 more staff planned to start. The home needs to have at least 9 staff on this course to ensure it meets the target of 50 as soon as possible. [by 2008] The overall percentage of care staff with this qualification is 10 . The manager is still exploring the use of a different training provider, or paperless National Vocational Qualification, due to problems with the present provider and the aversion for some staff to go to college. The home has also achieved registration as a training establishment for YMCA training. A number of staff have started on a Core Skills Practice which is described as a foundation stepping stone course to NVQ. The manager was informed that all staff who join the home need to complete foundational training within the first 6 months if they are not going on to National Vocational Qualification level2 or 3. This also applies to existing staff who the manager is hoping to motivate towards training. All new staff as seen in St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 18 records complete the Skills for care 6-week induction with a staff member completing this who had not started the course at the last inspection. The staff person confirmed this is in discussion along with the range of support she was receiving with her planned to start a National Vocational Qualification shortly along with a first aid course. The manager indicated that he is already making plans to introduce the new wider ranging Skills for Care 12 week induction effective from September 2006 The staffing files relating to the two newest staff were looked at and confirmed that all necessary checks such as references and referrals to the Protection of Vulnerable Persons Register has been carried out with Police CRBS applied for and received back. The home maintains an accurate rota and has sufficient numbers on duty to meet needs as reported at the last inspection. The home also indicates the capacity and role of each person marked on the rota. St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 19 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, & 38. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home benefits from an experienced and knowledgeable management team The owner [Responsible person] needs to demonstrate that the home is being sufficiently supported by sending regular monthly reports to the Commission. Resident’s financial affairs are soundly managed by the home where necessary. Supervision has now started for all staff. EVIDENCE: The manager is experienced, has the necessary qualification and has identified further training to update his knowledge and practice. The deputy manager has developed the care-plans with it identified that the overall running of the home will further improve once sufficient staff are trained and can take more St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 20 Responsibility. The administration of the home needs more attention to ensure sufficient time is spent on care-planning and staff development. Staff and records confirmed that all staff have now received at least one written supervision since the requirement was made 2 years ago. It was recommended to the home that supervisions are planned in advance to ensure that all full time staff are kept on schedule to now receive 6 per year Management is very visible in the home and residents spoken with where clear how to approach management when necessary. Quality monitoring tools are in place and much data is collected. This information has now been evaluated and fed back into care practice. The home has produced six monthly periodical reports and published the key findings in the service user guide [see standard 1]. These reports are based on the completed comment cards by service users and their representatives. The Inspector saw completed questionnaires from both long-term service users and respite users, all of which were positive from the most recent ones sampled. The questions cover a full range of areas such as cleanliness, food, activities, and suggested improvements. Respite users and their representatives are given questionnaires on departing from the home after each stay with a prepaid envelope. Interviews are also arranged where necessary. The overall Quality assurance practices will be complete once the new owners start sending the commission monthly reports of there visits to show the quality of care. The two owners have been doing weekly visits since last summer but are yet to send the Commission the necessary reports to show how the home is running and how they are measuring the quality of the care. A small number of residents have their personal allowances managed on their behalf by the management subject to their signed agreement. A sample of monies examined along with written records and running totals was all found to be in order. Most staff have received all necessary health and safety training such as Moving and Handling, First Ad, and Food Hygiene. All safety records are well maintained, as is all equipment. All Mains Electricity and portable appliances were tested in April 06 along with the Gas Boiler. St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 1 2 X X x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5[1][b] Requirement Timescale for action 10/08/06 2 OP3 3 OP7 That the Registered Person must ensure that copies of all service user [Resident] signed contracts are kept in the home available for inspection, and are in accordance to the required items listed in the standard. That Service users [resident] or their representative have a copy of their terms and conditions. Requirement made at the last 5 inspections. Requirement first made in 2004. 14[1]&15[ That the Registered person must 1] ensure that he can demonstrate that all users [Residents] have been assessed by the home before accommodation is provided. That this written assessment is available in the home, is full and shows a plan for daily living and longer term outcomes based on the home’s own needs assessment. That the needs of Respite users are reassessed on re-admittance when appropriate 15[1] That the Registered person must ensure that all service users [Residents] including Respite DS0000066217.V290276.R01.S.doc 10/06/06 10/08/06 St Peters Grange Version 5.1 Page 23 users have a care-plan to show specifically how needs will be met and that this is understood by staff. That any initial assessment or other information is updated and regularly reviewed to demonstrate how needs are met [see standard 3]. 4. OP16 18[c][1]& 22[3] That the Registered person must ensure that all necessary staff including Managers have appropriate Complaints and Grievance, handling training. Requirement of the last 3 Inspections. Requirement first made 11/08/05. 10/09/06 5 OP28 18[c][1] 6 OP30 18[c][1] 7 OP33 26 That the Registered person must ensure that sufficient staff are 10/11/06 studying for National Vocational Qualification level 2 in Care, by the date shown. Requirement of the last 2 Inspections. Requirement first made January 24, 2006. That the Registered Person must 10/10/06 ensure that all Care Staff receive Induction training to National Training Organisation specification and targets, and Skills for Care guidelines That all care staff receive Foundational induction training within the first 6 months of employment if they not already done this training or are starting National Vocational Qualifications. That this training is undertaken by all exisitng staff That the Registered 10/06/06 Provider/Person must ensure the resumption of Monthly section 26 inspection visits. That evidence is sent to the Commission of these visits on a regular monthly DS0000066217.V290276.R01.S.doc Version 5.1 Page 24 St Peters Grange basis. Requirement of the last 2 Inspections. Requirement first made January 24, 2006. 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 Refer to Standard OP7 OP7 OP7 OP36 Good Practice Recommendations That staff receive care-planning training. That Care Plans specifically show what assistance is required in order to promote the Independence skills of the individual. That Care-plans more clearly show strengths and weakness along with the range of choices the individual can make. That supervisions are booked and planned to occur for all staff every 2 months to ensure that the required frequency of 6 per year is kept on schedule. St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 St Peters Grange DS0000066217.V290276.R01.S.doc Version 5.1 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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