Inspection on 19/04/07 for Stockwell Grange Residential Care Home

This inspection was carried out on 19th April 2007.

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

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

Other inspections for this house

Stockwell Grange Residential... 23/03/09

Stockwell Grange Residential... 03/10/06

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

CARE HOMES FOR OLDER PEOPLE Stockwell Grange Greystones Stockwell End Tettenhall Wolverhampton West Midlands WV6 9PH Lead Inspector Key Unannounced Inspection 19th April 2007 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 Stockwell Grange DS0000067755.V335470.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. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stockwell Grange Address Greystones Stockwell End Tettenhall Wolverhampton West Midlands WV6 9PH 01902 752 353 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) Jasvinder Takhar Mr Arjan Bhoja Odedra, Mr Vijay Odedra, Daljit Takhar, Mrs Shanta Odedra Vacant Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd October 2006 Brief Description of the Service: Stockwell Grange formally Greystones provides accommodation and personal care for 19 people over the age of 60 years old. The lounge and dining areas are homely and comfortable. There are two double bedroom with the remaining all single occupancy and 10 rooms have en-suite facilities. They are all well decorated with many items belonging to service users. The home overlooks Tettenhall golf course and is situated in a private road approximately a half mile from Tettenhall village where there is a good range of small shops and a bus service to the city centre The current fees range from £370.00 to £400 for an en-suite single room per week. The home provides short stay and introductory stays when the home has a vacancy. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is on a Key Inspection, part of which included an unannounced visit undertaken on 19 April 2007. This unannounced visit started at 9.00 a.m. and lasted 7 hours and 45 minutes. The home had 12 places occupied and 7 beds remain vacant. The judgements made within this report are based upon information supplied by the home, and from interviews with staff and service users. During the course of inspection the assessment information and care plans were inspected for 4 service users. Medication administration was checked. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with Health and Safety legislation. A tour of premises was also undertaken and observation of care practice and interaction between staff and service users was also completed. Four service users’ files were looked at to enable the Inspector to monitor progress in meeting previous requirements. Discussion took place with 4 members of staff and several service users were spoken to throughout the day. The Acting Care Manager – Ms Yvonne Watkis was present throughout the inspection. On this occasion all the Key Standards of the National Minimum Standards were inspected. Issues raised through a formal complaint against the home by an anonymous complainant received by the Commission for Social Care Inspection (CSCI) in late January 2007,and Regulation 37 Notifications received from the home were also considered and discussed with the Acting Care Manager. What the service does well: Stockwell Grange care home is registered for 19 older people. The home makes every effort to provide individual with a good care to meet the assessed needs following a care plan. The home has a god key worker system and staff supervision system in place. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 6 The home communicates well with the families/friends and representatives of the service users. The visitors’ book indicated a lot of activity. The service users spoken with said that they are happy and content with living in a homely and caring place. Service users were in the lounges engaging in their daily routines and activities and they further commented that they were comfortable and satisfied with the care provided. The atmosphere within the home was observed to be relaxed, comfortable and friendly. Friendly rapport was also observed between service users and staff. Meals are varied balanced and well - presented to meet each individual’s choices, preferences and requirements. Most of the service users spoken to who could express themselves in a meaningful way expressed their satisfaction with the care they received and they commented “the food is very good here and tasty”, “I am very happy in this place” and “the staff are very good caring and kind”. “The new manager is very good and she sort things out for us, and she has already made this place more comfortable”. The home has introduced a training programme, which all members of staff are actually involved in. All staff have completed their NVQ Level 2 training. Thus this will ensure that they are improving their knowledge and skills to meet the changing needs of the service users. The home provides adequate standard of accommodation, and there are plans to extend the home and make further improvements to the existing facilities. What has improved since the last inspection? It was noticeable that there have been considerable improvements made to the home and the care provided since the change of ownership and the new Acting Care Manager. The recent improvements include the redecoration of the Hall/Reception area, ground floor, and partly first floor corridors, Majority of the bedrooms have been redecorated and also refurbished with new furniture and colour co-ordinated bedding and curtains. New floor covering has been fitted to the hallway/reception, ground floor corridors, dining room, and several bedrooms. In addition, the home has introduced a good staff supervision, training programme and provided new service users’ files, care plans, and new administration of medication system. The new Acting Care Manager was appointed in January 2007 and she already has embarked on improving care of service users and the environment of the home. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is (Adequate). This judgement has been made using available evidence including a visit to this service. Stockwell Grange provides information to prospective service users and their families to enable them to make decisions about whether or not they wish to live at the care home, but it is not as up to date as it should be. All prospective service users receive a full/comprehensive needs assessment prior to admission to admission to ensure that their needs will be met. The home does not provide intermediate care. EVIDENCE: The Acting Care Manager stated that the home has produced the final drafts of the Statement of Purpose for the home and the Service Users’ Guide. The Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 10 Acting Care Manager stated that both of these documents would be reviewed/updated shortly in the light of recent amendments to the Care Homes Regulations 2001 (as amended in 2006) and will be made available to all prospective service users and the existing service users, and in suitable format, including in large print. Admissions are not made to the home until a full needs assessment has been undertaken. The Manager is then able to confirm that the home can meet the needs of the individual through the service they deliver as detailed in the Service Users’ Guide and Statement of Purpose. For people who are selffunding and without a care management assessment, they always receive assessments by the Acting Care Manager. The four service users’ files and care plans were inspected which contained pre-admission assessments of the service users’ needs, both from assessments by the home’s senior staff and other relevant professionals. Observations and discussions with service users, Acting Care Manager, and staff on duty indicated that the home continues to meet the individual needs of all the service users accommodated at the home in a satisfactory and sensitive manner. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is (Adequate). This judgement has been made using available evidence including a visit to this service. Each service user has an individual plan of care that does not details how their needs will be met. Health needs are addressed promptly. Medication is generally managed safely and service users are protected by the home’s policy and procedures. Service users are treated with respect and dignity, and their right to privacy is understood and upheld. EVIDENCE: All service users undergo an assessment of their needs prior to admission to the care home. A Care Plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plans and monthly reviews are implemented. Four service users’ care plans and files were examined in detail and it was noted that the short-term and long-term goals, aims and objectives were not Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 12 clearly identified and appropriate interventions required to put them into action to meet the individual service users’ needs also were not identified. It was noted that the care plans are being reviewed on a monthly basis. The daily care (day and night) formats were also examined and it was noted the quality and detail of recording needs improvement. The Acting Care Manager stated that she will ensure that the staff are aware of the importance of including all information regarding service users’ well being, and all the entries made by staff are always to be cross-referenced to care plans. The Acting Care Manager also stated that the revised and updated formats of care plans and daily care recordings will be implemented immediately; and the staff will be closely supervised and supported to make further improvements in daily care recordings as a matter of priority. The home maintains records of all health checks carried out by doctors, opticians, dentists, district nurses and chiropodists. It was also noted that the home ensures that the detailed nutritional screening is undertaken, including a weight gain and loss record are maintained and appropriate action is taken if required. Service users’ health care is closely monitored and appropriate medical care services are sought as and when required. It was observed on the day of inspection that no personal care interventions were undertaken in communal areas. In addition, consultations with health and social care professionals are carried out within the service users’ bedrooms. Visitors are able to meet service users in their bedrooms, small lounge or conservatory on the ground floor, which offers privacy when not being used. It was observed that service users were being treated with respect and staff are working both professionally and sensitively in meeting individual needs. The Inspector spoke at some length with several service users and all of them commented positively about their care and they felt that they have everything that they need. Four service users stated that “the carers are very good and kind and they look after us very well”. Three other service users said that the carers are always there to help, and we are pleased with them. Generally the service users appeared to be content, comfortable and happy. The service users were complimentary regarding the quality of their lives and the care they are receiving at the home. It was noted during discussions with service users that the carers are pushed for time, because they are expected to cover cleaning and catering duties. Evidence was gathered from the staff records and from discussion with the Acting Care Manager and staff on duty that all senior carers, who are responsible for the safe handling and administration of medication have completed their training in safe handling of medication. The Acting Care Manager stated that the home has recently changed the medication Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 13 administration system to Boots monitored dosage system. This system appears to be working well. All senior staff have been trained to use the new system before they are allowed to administer medication. Records seen included medication received, administered and leaving the home. It was noted that there were no photographs of service users on their medication MAR sheets, which could increase the potential risks of maladministration of medication. It was also noted that the mobile medication trolley was not securely and safely stored after use in the Manager’s office. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in these outcome areas is (Adequate). This judgement has been made using available evidence including a visit to this service. The home does not provide a structured programme of social and leisure activities and outings, which are designed to meet the service users’ preferences, and capabilities. The Acting Care Manager and staff encourage families and friends to maintain good contact with their relatives at the home. Service users are positively helped to exercise choice and control over their lives as far as practicable and safe to do so. Meals at Stockwell Grange are a good homely type, offering choice, variety and catering for special dietary needs and requirements. EVIDENCE: It was noted that the home does not provide a structured programme of social and leisure activities inside and outside the home in accordance with the service users’ choices, preferences and capacities. There is no proper system of maintaining records of activities in the home. The home does not have a staff member designated to organise social and leisure activities who identified interests that the service users wish to pursue. The care plans does not clearly Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 15 identify the social and leisure needs of service users. There was no system in place of informing the service users about the availability of social and leisure activities. It was also noted that there is very little in the way of entertainment and activities provided within the home and no outings and trips have been arranged since the last inspection. However, the new Acting Care Manager stated that a senior carer has been identified to act as an activities coordinator and she will have the responsibility to plan and implement in the home in liaison with other carers a programme of social and leisure activities for all service users. The external entertainers would also be invited/requested to deliver entertainment in the home in accordance with the service users’ choice, capabilities and preferences. The Acting Care Manager must ensure that the social and leisure needs of service users are clearly identified in their care plans, and any such activities enjoyed by the service users are incorporated into their individual care plans. All the service users spoken to stated that they are in touch regularly with their friends and family members and spoke about their visitors’ interest in their daily care matters. The visitors’ book showed considerable activity. However, no visitors came to the home to see the service users on the day of inspection, so the Inspector was unable to get direct feedback from the visitors. The Acting Care Manager stated that the service users are positively assisted and helped to exercise control over their lives as far as possible, practicable and safe to do so. A close liaison is maintained with the relatives and representatives, where the service users are not able to make certain decisions. Service users and their relatives are informed of the availability of the Advocacy Service based at the local Age Concern. Several service users told the Inspector “the food was very nice and tasty”. The consensus of service users was the range, quality and choice of food provided was very good and the home caters for those service users who have individual preferences and medical needs. The Acting Care Manager stated that the current four weekly menus were changed in early April 2007 and in consultation with the service users. The catering staff are well trained in food safety and hygiene matters. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is (Adequate). This judgement has been made using available evidence including a visit to this service. Concerns and complaints are dealt with promptly and professionally. Service users are protected from abuse by the home’s policies and procedures. Formal training is required for all staff to ensure that service users are protected from abuse. EVIDENCE: The home has a good complaints procedure, which is referred to for information in the Service Users’ Guide. There is a satisfactory system of recording complaints and concerns. It was noted that there has been one anonymous complaint made against the home in late January 2007 and was directed to the Commission for Social Care Inspection (CSCI). The Registered Provider has investigated and addressed appropriately the issues raised by the complainant (i.e. no hot water in rooms, meals that the service users are eating, building work that is being carried out and 1 or 2 carers to 12 service users.) and a formal response was promptly sent to the CSCI. The anonymous complainant did not leave any contact for receiving the response from the Registered Provider. The CSCI is satisfied with the outcome of this anonymous complaint investigation and response. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 17 Service users, when asked were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff in charge or the manager. The home has not had to report any vulnerable adult protection issues. The home has good policies and procedures regarding restraint, dealing with aggressive behaviour and prevention of abuse, which includes whistle-blowing policy. The Acting Care Manager stated that adult protection issues are discussed during induction training and supervision meetings. However, training in adult protection issues has not yet been provided to all members of staff. Service users stated that they are satisfied with the service provided, feel safe and well supported by staff that have their protection and safety as a priority. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is (Adequate). This judgement has been made using available evidence including a visit to this service. General standard of the environment is good providing a homely and secure place to live but needs some improvement to décor, furniture, and safety matters. The home is generally kept clean and hygienic. EVIDENCE: The home is accessible, secure and generally well - maintained. The home has adequate communal space for dining and lounge areas. All bedrooms are of good size and 10 have en-suite facilities. It was noted that a considerable amount of work has taken place within the home since the change of home ownership. All the corridors on the ground, first floors, hallway/reception Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 19 areas and dining room have been provided with new floor covering. Several bedrooms have been redecorated, refurbished and fitted with new floor covering and new furniture items. General appearance of the internal environment is good, but a number of rooms on both floors are in need of redecoration and new floor covering. The bathroom on the first floor is in need of refurbishment and to be made fully operational. A rolling programme of redecoration and refurbishment need to be introduced to modernise and improve the environment. The ceiling in the conservatory needs to be made safe so that the service users can make use of this facility. The laundry room is in need of refurbishment. The extractor fan, dishwasher, cracked floor tiles and fly screen to the back door in the kitchen are in need of repair/replacement. It was noted that the home does not provide a staff room, this should be addressed in the forthcoming extension building work. The Registered Providers should continue to comply with the recommendations/requirements contained in the recent reports of the West Midlands Fire Authority and Wolverhampton City Council’s Environmental Health Department. The Acting Care Manager stated that there are also plans to extend the home and to further improve the facilities and initial building work has already commenced. All the safety regulations are to be observed during this activity. The home was found to be clean tidy and free from any unpleasant odour. However, the home only employs one part-time cleaner for five days a week. With the building work and redecoration that is taking place within the home there should be increase in cleaning staff by another part-time staff to maintain the standard. The home has good policies and procedures regarding infection control and staff have received training in food hygiene and infection control matters. From observations and discussions with staff they appeared to be conscious of the dangers of cross-infection. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is (Adequate). This judgement has been made using available evidence including a visit to this service. The home is not adequately staffed at all times, which could impact on the quality of care provided and the ability of the home to meet the needs of the service users. The home continues to support staff to complete training, but not all of the staff are yet adequately trained to do their jobs. Recruitment procedures have improved but require fine-tuning to fully protect service users. EVIDENCE: Information provided by the home and the available staff rotas on the day of inspection indicated that the home is not adequately staffed at all times. The Acting Care Manager’s hours are supernumerary and there are three carers on duty in the morning, two in the afternoon and two waking night staff. The home also provide cooking cover for seven days a week, (but not tea-times) and a cleaner employed to provide cover for five days a week. The carers are expected to cover duties in the kitchen in the evenings. The carers are also expected by the Registered Providers to cover domestic and laundry duties more particularly during the weekends. During the Inspector’s meeting with the staff on duty, they also stated that they feel under pressure and in particular in the mornings and evenings. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 21 The staffing deficiencies have been identified at the previous inspection and in the recent complaint against the home received by the CSCI. It was noted as the numbers of service users increase and the dependency levels rise, the staff are struggling to provide quality time and a good standard of care. Also it was noted that the staff have little time to provide social and leisure activities. In order to provide a good standard of care and upkeep the cleanliness of the home, the Registered Providers need to review the staffing levels and then need to take appropriate action to provide adequate numbers of care and ancillary staff on duty at all times. The Acting Care Manager’s hours are in addition to the above staff hours and are supernumerary to allow Ms Yvonne Watkis to manage the care home effectively and efficiently, for example, staff supervision, training and development, new staff recruitment and induction, care planning and reviews, maintenance of records, liaison with external agencies/professionals, service users and their relatives, regulatory bodies, home’s compliance with fire, health and safety procedures and regular tests/checks of safe working systems and equipment and maintaining records. It was noted from the staff training records and discussions with staff and Acting Care Manager that all care staff have completed their NVQ Level 2 training. The Acting Care Manager stated that most of the staff have also completed their safe working practice topics training and a new member of staff need to undertake her induction training in accordance with the Skills for Care standards/requirements. The home now operates an acceptable recruitment procedure since the new ownership and management has taken over. On inspecting four staff files, it was noted that now all staff are POVA and CRB checked. Two references were not available on those members of staff who had been employed in the home for several years. One member of staff did not receive her contract of employment and was informed that she has given notice to leave the home shortly. All staff files need to have a form of identity i.e. staff photographs or copies of birth certificates as a form of Identity All staff at the home are committed to developing their knowledge and skills through training and have regular opportunities to do so through external and internal training courses and activities. The senior care staff have attended course on safe handling of medication, and other care staff also attended courses on fire safety, health and safety and moving and handling. It was noted from the staff training records that not all members of staff have received training in adult protection issues, fire, health and safety, infection control, first-aid, including the home having sufficient numbers of fully qualified staff in first-aid to cover all shifts, and food hygiene. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 22 The Acting Care Manager stated that she will be preparing a training matrix on staff and devise an efficient training recording system. Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38. Quality in this outcome area is (Adequate). This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. The Manager is not registered with the Commission for Social Care Inspection. Service users can be assured that the home is generally run in their best interests. Their financial interests will be safeguarded. The home generally does promote the health, safety and welfare of its service users and staff, but need some further improvements. EVIDENCE: The home is without a Registered Manager. However, the Registered Providers have appointed a new Acting Care Manager in January 2007. Ms Yvonne Watkis is qualified with NVQ Level 4 and RMA. She appears to be managing Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 24 the home well. Ms Watkis stated that she will be submitting her application to register with the CSCI on completion of her “probationary period” shortly. There are clear lines of responsibility and accountability within the home and the Acting Care Manager is well supported by the Registered Provider. The home has formal staff supervision in place and the new Acting Care Manager have already implemented supervision of staff and meeting with staff and service users. Observations made and discussions with service users and staff indicated that the new Acting Care Manager is very approachable and she operates an open door policy. The staff and service users, who could express themselves stated that they are happy to approach the Acting Care Manager and staff with any problems they might have and were confident that they would respond to them. It was noted the home has a Quality Assurance monitoring system in place, which includes questionnaires to service users, visitors and relatives to obtain feedback on quality of service. The feedback from the last issue of 8 questionnaires to service users was positive regarding the improvements made since the change of ownership with all feedback stating they are satisfied with the care they are receiving. The Acting Care Manager confirmed that she has recently sent out the questionnaires to all service users, their relatives/friends and other visitors. She will complete the report by the end of May 2007 on the feedback, and will be made available in the home and a copy to the CSCI. It was noted that the Registered Provider has undertaken Regulation 26 visits to the home during the spring, but did not follow through the issues affecting the management of the home, and also requirements contained in the previous inspection report dated 3rd October 2006. The Registered Provider when undertaking Regulation 26 visits to the care home need to look at all aspects of management, care and protection of service users and health and safety areas and visits recorded and appropriate action taken to rectify any outstanding issues. The copies of the monthly Regulation 26 visits reports should be kept in the home and made available for inspection by the CSCI. All the financial records and administrative procedures relating to service users’ monies within the home that were inspected were found to be well ordered and maintained. The home has good health and safety policy and procedures, and all staff are aware of their responsibilities regarding these issues and a number of staff have received training in these issues. Matters pertaining to fire safety and environmental health needs to be maintained to the required standards and all the issues identified in the recent inspection reports of the Fire Safety Officer and the Environment Health Officer should be addressed appropriately. All safety systems and equipment are regularly checked and well maintained and records of all tests/checks are kept up to date. However, it was noted that the Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 25 fire alarm system was not tested since 27 February 2007, and the two fire doors to both lounges failed to close when the staff tested the fire alarm system on the day of inspection. The identified defects needs rectifying, and the fire alarm system also needs testing on a weekly basis. Stockwell Grange DS0000067755.V335470.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Stockwell Grange DS0000067755.V335470.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 OP12 Regulation 15,16 & 17 Requirement The Registered Provider must ensure that the service users are provided with a range of social and leisure activities both indoor and outdoor of the Home. The activities must be varied in range and appropriate, and in accordance with the service users’ choice, preference and capacities; and records are maintained of all activities enjoyed by the service users and must also be incorporated into the individual service users’ care plans. The Registered Provider must ensure that all staff receives formal training on protection of vulnerable adults from all forms of abuse. Timescale for action 30/06/07 2. OP18 13 30/06/07 3. OP27 18 The Registered Provider must 30/06/07 make appropriate arrangements to provide adequate cleaning cover for seven days a week, catering cover at teatime in the evenings and adequate care staff DS0000067755.V335470.R01.S.doc Version 5.2 Page 28 Stockwell Grange cover throughout the week. 4. OP29 17 (Schedule 2) & 19 The Registered Provider must 30/06/07 ensure that two written references are obtained before appointing a new member of staff, and those existing members of staff, who are without two appropriate references on their files; and that all staff files must have their current photographs and/or copies of their birth certificates as a form of identity. The Registered Provider must ensure that the home provides an induction programme for new members of staff, which meets the Skills for Care standards. The Registered Provider must ensure that an application is brought forward to register the Acting Care Manager with the CSCI as a registered manager as a matter of priority. 30/06/07 5. OP30 18 6. OP31 8 30/06/07 7. OP30 18 The Registered Provider must 31/07/07 ensure that those members of staff who as yet have not received training on safe working practice topics must do so. The Registered Provider must ensure that all service users must have their photographs on their care plans/files. The Registered Provider must ensure that the mobile medication trolley stored in the Manager’s office must be made safe and secure. The Registered Provider must ensure that the bathroom on the DS0000067755.V335470.R01.S.doc 8 OP7 17 (Schedule 3) 13 & 18 30/06/07 9 OP9 30/06/07 10 OP19 23 30/06/07 Page 29 Stockwell Grange Version 5.2 first floor is refurbished and made fully operational; the ceiling in the conservatory is repaired; extractor fan, dishwasher, cracked floor tiles, and a broken fly screen to the backdoor in the kitchen are appropriately repaired/replaced; and all the recommendations contained in the recent inspection reports of the Environmental Health Officer and the Fire Safety Officer must be implemented appropriately. 11 OP38 23 (4A) The Registered Provider must ensure that the fire alarm system is tested on a weekly basis and all records of tests appropriately maintained and any defects identified must be rectified. The fire doors to both of the lounges must close to their rebate. The Registered Provider must ensure that a copy of the monthly reports of Regulation 26 visits to the care home are recorded, appropriate action taken on any defects/deficiencies, and kept in the home and made available for inspection by the CSCI. 30/06/07 12 OP33 26 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP14 Good Practice Recommendations The Registered Provider should ensure the regular DS0000067755.V335470.R01.S.doc Version 5.2 Page 30 Stockwell Grange residents’ meetings take place and are recorded in order to consult with the residents regarding the care they receive. 2 OP20 The Registered Provider should consider providing the home with a staff room within the planned extension building work. The Registered Provider should provide service users and their relatives an updated/revised Statement of Purpose for the home and the Service Users’ Guide. The Registered Provider should ensure that all service users’ care plans contain detailed goals, aims and objectives recorded; and details and quality of daily care recording should be improved. The Registered Provider should consider providing all care staff training in safe handling of medication as a matter of good practice. The Register Provider should ensure that photographs are provided on all service users’ medication MAR sheets as a matter of good practice. 3 4 OP1 OP7 5 OP9 6 OP9 Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stockwell Grange DS0000067755.V335470.R01.S.doc Version 5.2 Page 32 - 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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