Inspection on 19/09/07 for The Grange

This inspection was carried out on 19th September 2007.

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

Other inspections for this house

The Grange 19/10/08

The Grange 23/10/06

The Grange 18/03/06

The Grange 08/07/05

The Grange 24/01/05

The Grange 03/08/04

The Grange 24/02/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOME ADULTS 18-65 Grange (The) 2 Mount Road Parkstone Poole Dorset BH14 0QW Lead Inspector Heidi Banks Key Announced Inspection 19th September 2007 14:30 Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grange (The) DS0000004086.V351048.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grange (The) Address 2 Mount Road Parkstone Poole Dorset BH14 0QW 01202 715914 01202 743557 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) www.leonard-cheshire.org.uk Leonard Cheshire Mr Paul Bulgarelli Care Home 26 Category(ies) of Physical disability (26) registration, with number of places Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate a maximum of seven service users in need of personal care in the category of PD(E). 23rd October 2006 Date of last inspection Brief Description of the Service: The Grange is a home owned by the Leonard Cheshire Foundation, a national charity, and accommodates up to twenty-six adults who have a physical disability. There are four apartments on the ground floor of the home providing accommodation for a total of twenty people and a respite unit on the first floor providing further accommodation for either temporary or permanent residents. Each unit has a kitchen / dining room and two bathrooms, and service users have their own bedroom. A communal area in the centre of the building comprises a seated coffee area, with a fishpond, where guests and visitors can also sit. There is a large paved courtyard for use in the summer. The Grange offers adapted living facilities to accommodate people who use wheelchairs. There are adapted baths, beds, a lift, automatic doors and manual and electric hoists. People who use the service have access to some adapted vehicles available to provide transport to service users. The Grange is situated in a residential area of Parkstone, close to local shops and amenities. A bus route is located nearby. According to information supplied by the Registered Manager on 8th November 2007, the current fees for residents at The Grange range from £589 to £908 per week based on assessment of individual needs. This fee excludes certain items such as hairdressing, chiropody, personal toiletries, activities, magazines, newspapers and holidays. Service users are invoiced separately for their use of the home’s transport and make a contribution towards a television licence. Further information on fair terms of contracts and care home fees can be found on the Office of Fair Trading’s website: www.oft.gov.uk. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key announced inspection of the service. The purpose of this inspection was to assess the home’s progress in meeting the key National Minimum Standards since the last key inspection of the service in October 2006. The on-site inspection took place over approximately sixteen hours on 19th September, 16th October and 17th October. On 19th September the lead inspector was joined by an ‘Expert by Experience’ from the Southampton Centre for Independent Living for approximately two-and-a-half hours. ‘Experts by Experience’ is a project that involves people who use services in the inspection of those services. Their role is to join inspectors to help them get a good picture of the service from the viewpoint of the people who use it. The Expert by Experience, who was accompanied by her Personal Assistant, met with a group of six people who use the service. People’s views obtained from this discussion have been reflected throughout this report. During the inspection we were able to take a tour of the home and talk to some people who use the service. Discussion took place with the Registered Manager, Paul Bulgarelli, and several members of the staff team. We were also able to meet with the Facilitator from the Leonard Cheshire Service User Support Team who has regular contact with the home in her role. A sample of records was examined including some policies and procedures, medication administration records, health and safety records and service user and staff files. Prior to the inspection, an Annual Quality Assurance Assessment (AQAA) was completed by the Registered Manager and submitted to the Commission. Surveys were distributed by the home to people who use the service, their relatives, care workers in the home, care managers and health care professionals on behalf of the Commission. Eleven completed surveys were received from service users, twelve from care workers, four from relatives, five from care managers and two from health care professionals who have contact with the home. A total of twenty-four standards were assessed at this inspection. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 7 Record-keeping of meals eaten by people who use the service has improved since the last inspection. Records are now clearer and give more detailed information about what individuals are eating on a daily basis. Following concerns at the last inspection about the security of the home, the manager has told us that he has taken steps to consult with people who use the service. The manager has told us that people who use the service are happy with the security measures that are in place. It is suggested that the home keeps this issue under review because, while promoting access and egress to the home promotes people’s independence and is a very positive thing, the home also has a responsibility to safeguard the people who live there and ensure that it is a safe place to live. The provider has taken some steps to meet a requirement made at the last inspection to review staffing numbers within the home. This has included reducing sickness absence within the staff team, recruiting a team of bank staff and starting to look at more flexible shift patterns. What they could do better: As a result of this inspection two requirements have been made. Feedback from people who use the service, some relatives, care workers, care managers and health care professionals indicated that the home is still running on the ‘bare minimum’ of staff, particularly in the evenings and at weekends. There was evidence to show that people’s needs are changing and the home must take action to ensure that they always have enough staff on duty to meet people’s personal care, emotional and social needs promptly, safely and effectively. Following a warning letter issued by the Commission in October 2006 and this inspection the provider has now agreed that they will increase staffing levels in the evenings from four to five to support twenty service users. The home has been told that they must now provide evidence that the revised staffing levels they plan to implement fully meet the assessed needs of people who live there and achieves positive outcomes for them. The home did not fully meet the regulations in relation to recruitment practices. They must review their procedures to ensure that they have all the information they need to make robust decisions about the people they employ to work with service users. Six recommendations have also been made where practice should be improved. More attention should be paid to supporting people to set and Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 8 achieve personal goals as part of their individual service plans. Risk assessments should also be reviewed on a regular basis to ensure they continue to reflect the needs and preferences of people who use the service. People’s support plans should also contain some specific information about the way each person needs their medication to be administered so that care workers have all the information they require to be able to support people with this aspect of their care. The home should ensure that they follow their organisation’s complaints procedure when they receive a complaint and respond within an appropriate timescale so that people know their concerns are taken seriously. Health and safety practices are generally well-managed in the home but consideration should be given to the frequency and times of fire practice evacuations. This is to ensure that all staff and all service users have the opportunity to participate in an evacuation, at various times of the day, so that they know how to respond if an emergency occurs. 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. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have their needs assessed before they are admitted to the home which ensures that plans can be put in place to promote a smooth transition. EVIDENCE: The home’s Annual Quality Assurance Assessment told us that there have been three people admitted to the service in the last twelve months. In order to ensure the service can meet people’s needs the home tells us that they have a written assessment framework and liaise closely with placing authorities so that people’s needs are identified prior to admission. This was confirmed in surveys from care managers, one commenting that they had provided a full care plan on admission and another stating that their experience of liaising with the home regarding the placement of a client had been good. People who use the service told us in surveys that, on the whole, they had received enough information about the home before they moved in to enable them to choose whether it was the right place for them and had been able to visit the home before admission. A relative of a person recently admitted to the home Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 11 also stated that they had been given enough information about the care home to support their decision-making. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lives but further development of goal planning processes will help ensure that the service they receive is consistently based around their aspirations. EVIDENCE: A sample of individual support plans were seen at this inspection. Plans are kept by the service user in their bedrooms so that they are easily accessible to both them and their care workers. People who use the service had been involved in writing a ‘Personal Profile’ in their plan which gives some insightful information about who they are, the things they enjoy and what is important to them. People’s routines had been clearly documented, for example, the help they require in relation to their personal care or with managing their money on a daily basis. There was some information in one plan seen about the individual’s personal interests and who would be involved in supporting Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 13 them to pursue these. However, the goal-setting documentation was limited and there was insufficient detail to show the progress being made towards achieving these. One person who met with the Expert by Experience talked about their goals and aspirations but it was noted that other people in the group found the idea of achieving their personal goals difficult to grasp. For example, two service users stated that they would like to go on holiday but both said they would be unable to go despite the Expert by Experience’s suggestion that this may be possible in the longer term if support was available to plan and research funding. The manager told us that some people living at the home had arranged holidays for themselves very successfully. Discussion with the service’s Training and Development Officer indicated that further training for staff on goal-setting processes could be implemented to ensure that staff understand how they can help people set and work towards their goals and make this an integral part of their role as a key worker. One person spoken with during the inspection told us that they were able to make decisions about aspects of their everyday lives in the home, for example, where they eat, what they eat and the time they want to go to bed. Another person commented that on a Friday they have a lie-in as it is their ‘day off’ and this is respected by staff. A third service user told us that they had chosen to have a light supper in their bedroom that evening which staff had supported. Issues around promoting choice were discussed with staff who confirmed that in one apartment, service users tend to choose to eat together but in other apartments people choose to eat at various times. Staff spoken with were keen to promote choice although indicated that doing so in the evenings with current staffing levels was sometimes difficult. Residents’ meetings are held on a regular basis in the home and are attended by a Facilitator from the Leonard Cheshire Service User Network Association (S.U.N.A). Minutes of meetings seen demonstrated that it is a forum for people to discuss issues that are important to them and for their views to be fed back to management. The S.U.N.A. also holds regional committee meetings. Minutes of a meeting in July 2007 were seen, six service users from The Grange listed as attending. Issues discussed included the organisation’s new transport policy, the campaign to promote people’s use of public transport, moving from residential care to living in the community, the work of the Leonard Cheshire Campaigns Team and the organisation’s new logo. This showed how people living in services are kept updated on national issues and developments within the organisation. Risk issues were given consideration in support plans seen. For one service user there was a risk assessment in relation to taking medication which indicated that medication would be managed by staff. This was last reviewed in April 2006 with a review date stated as ‘every six months’ although there was no evidence to show that this had taken place. Discussion with some service users indicated that their independence in the home and community is generally promoted although one person expressed some concern that health Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 14 and safety issues may restrict their opportunities to pursue a specific personal goal; ‘the home is too restrictive about some things’. Discussion with the manager indicated that advice is being sought around health and safety issues to help the service user achieve his goal with the minimum risk. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who are able to be independent are empowered to be so. However, those who require more support experience more restrictions on their one-toone time and community access which means that the service is not always person-centred. EVIDENCE: People at The Grange were seen to have diverse needs. The service user group at the home are mainly young adults but there are some service users who are approaching or over the age of 65. As a result the service has to support a group of people who have a range of lifestyle needs and choices and want different things from their support package. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 16 Discussion with service users and review of surveys indicated that some people attend day services or college as part of their weekly routines. Where some service users have an interest in football, arrangements have been made for them to go to matches with a member of staff who shares their interest. One person spoken with during the inspection told us that this was a really positive activity that they really enjoyed. Conversations with the manager and some members of the staff team indicated that where people wish to be independent in accessing the community and organising activities for themselves, this is promoted. Several people at the home have bus passes which enable them to use public transport for free. Discussion with staff indicated that two people in particular are very confident in going out independently and the home allows them the freedom to do so. This was echoed by a family member of a service user who commented in a survey that the home’s philosophy suited their relative who likes to be as independent as possible. The service is currently taking steps to promote access to transport for people with disabilities as part of ‘Make a Difference Day’ and, at the time of the inspection, a ‘Wheelchair Skills’ day was being planned to support service users in building confidence in using public transport. Out of eleven surveys received from people who use the service, six felt that they could make decisions about what they do each day with five indicating that this was usually or sometimes the case. Reasons for people not being able to do what they want to do were stated as depending on staffing levels particularly in the evenings and weekends; ‘They don’t always have drivers available to take me to the places I would like to go’; ‘One has to be flexible and fit in with others’; ‘It is not always possible to go out due to staffing levels at the weekend’. People who met with the Expert by Experience told her that one-to-one time was available for them once a week usually for a two-hour slot. This was confirmed by staff spoken with during the inspection who reported that they ‘get each person out once a week’. One service user told us that they had missed their ‘slot’ the previous day as a member of staff had been off sick. They were not sure if or when it would be re-scheduled. People told the Expert by Experience that staffing levels and transport costs were the main barriers to them accessing social and leisure opportunities. They also felt that, under the current systems, they have to plan activities ‘months in advance’ and were unable to be spontaneous. Following their discussion the Expert by Experience felt that people’s one-to-one time needed to be quality consistent and offer greater flexibility for individuals. The manager of the home has told us that people who use the service access a range of activities including trips to ‘Biker Nights’ on Poole Quay, Sunday lunches at the British Legion Club and evening music concerts. Two people spoken with at the inspection stated that they used to enjoy being involved in doing the weekly grocery shop with staff. However, they told us that the home now places their order on-line and they are only involved in compiling the shopping list. It was mentioned by one service user that staff continue to shop locally for fresh fruit and vegetables. When asked if they Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 17 were able to be involved in this, the service user told us that they felt they were not able to participate as getting their wheelchair into a vehicle would take too long and staff were pushed for time. Both service users spoken with about this issue told us that they missed helping with the grocery shop. The manager has told us that people wishing to participate in the weekly shop can be involved in doing this. The new transport policy was discussed at length with the Registered Manager and a Facilitator of the Service User Network Association. They were aware that the policy had proved unpopular with some people who use the service. The Registered Manager confirmed that service users had been consulted about the policy at a national level and their views had been heard by the organisation’s Head Office, representatives from which had visited The Grange to discuss the policy further. The Registered Manager reported that the policy charged people per mile which, in fact, was a fairer system than the previous system where everyone had been charged the same amount irrespective of how many times they had used the home’s vehicles or how far they had travelled. Concerns about these issues were expressed by two out of the four relatives responding to the survey; ‘There have been times when X has not been able to go out when they want due to a lack of drivers’; ‘X rarely goes out. X is virtually imprisoned in the home. X likes to go out to gardens, a park, walk in the country or by the sea but this rarely happens – simple things’. The same relative reported that the person’s key worker keeps a diary of events and activities; ‘the entries are weeks of doing almost nothing…last month X’s transport bill was £3 for one outing to the Dolphin Shopping Centre…one outing in four weeks is not acceptable.’ Both relatives stated that they felt that the home needed more staff to be able to facilitate more social opportunities ‘…in particular a person dedicated to the interests of the clients, not their physical care only’; ‘More staff availability to enable residents to have more choice to go on outings’. These comments were discussed with the Registered Manager who indicated that service users were given choices but did not always want to participate when activities were suggested to them. He has also told us that there has been some inaccurate recording by care workers which means that some activities and choices made by people have not been documented. The views of care managers and health professionals on people’s lifestyle in the home were obtained through surveys. Comments received included ‘…limited social activities to meet individual, high dependency needs’; ‘I observed several residents watching television but observed little social interaction between them, and them and staff’; ‘Staff ratio at weekends could be improved to provide more activities for residents’. One professional stated that they had observed a person in a wheelchair near to the serving hatch, whilst staff were working in the kitchen. They noted that the individual seemed happy to be part of this but felt that staff should be offering activities Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 18 to provide mental and social stimulation and value for money. The same professional stated that they felt staff would benefit from more training in this area or the service would benefit from an Activities Co-ordinator. People spoken with during the inspection indicated that they have regular contact with their family. At the time of the inspection, two service users were being visited by members of their family. One relative spoken with stated that she enjoys supporting her daughter in going to bed when she visits each week. Staff were supportive of this and were seen to welcome her involvement. Surveys from relatives indicated that the home did well at supporting their service user at keeping in touch with them; ‘X requires help to make ‘phone calls – this is never any problem to the staff.’ All four relatives responding to the survey indicated that they were always kept up-to-date with important issues affecting their relative. Discussion with care workers indicated their awareness of people’s rights. One care worker stated in a survey that they felt the home places a ‘special emphasis on service users’ rights to choice, privacy, dignity and independence.’ This was echoed in responses from care managers, four out of five of whom indicated that the home always respected individuals’ privacy and dignity. Observation of care workers interacting with service users showed evidence of respectful relationships and friendly rapport. People who use the service are able to gain access to their apartment and bedrooms at all times and the home issues special key fobs to residents to enable people to access the building after 5pm when the main door is locked. However, based on discussion with six people who use the service, the Expert by Experience felt that people experienced limitations to having real choice and control over aspects of their daily lives and the day-to-day running of the home on a local level. Some staff spoken with acknowledged that while they are aware of people’s rights to a person-centred lifestyle, in practice this can be difficult to achieve given current staffing levels. Each apartment in the home takes responsibility for purchasing its own groceries. Discussion with service users during the inspection indicated that they have input into meal choices. Inspection of records in each apartment showed that people’s individual choices for meals are respected and where people had chosen to eat different suppers this had been provided. Since the last inspection, recording of meals eaten has improved and entries were clearer and individualised. In addition, people indicated that there is flexibility regarding where they choose to eat their meals. For example, on the day of the inspection, two people in one apartment had chosen to eat in their own rooms. Each apartment has a kitchen / dining area which people can access at all times. Where people use specific aids to support their eating and drinking this was clearly documented in their support plans; ‘I eat very small amounts using my special bowl and spoon. I do not like large cutlery...I have special cups to drink from with a lid.’ Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 19 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of people’s personal and health care support demonstrate good practice. However, people’s opportunities to receive person-centred care that is consistent and responsive to their needs and preferences are restricted by staffing levels. EVIDENCE: Out of eleven service users responding to the survey, six indicated that the staff ‘always’ treated them well with the remaining five indicating that this was ‘usually’ the case. Responses from care managers reflected this with people telling us that the care service is ‘very supportive of individual requirements and support needs’; ‘Good key worker support’; ‘Staff attentive to my service user’s individual needs’. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 20 Support plans seen showed some very detailed information about the assistance people require with their personal care. Where one person has a stoma, actions to be taken by staff to clean and change the stoma had been documented including measures to promote good hygiene. Comments received from people who use the service and their relatives indicated that the best care came from care workers who knew the service user well, for example their key worker or others who have experience of working in that apartment. Care was reported to be less effective where care workers were not as familiar with people’s individual needs and preferences. From some comments received in surveys and from people’s discussion with the Expert by Experience some concerns were raised about the quality and consistency of care at times. One person commented in a survey; ‘My key worker is excellent. However, other staff sometimes don’t look after me as well. For example, sometimes my teeth are not cleaned as there isn’t time to do them before I go out…my teeth are suffering as a result.’ The relative of a service user reported that they had noted some shortfalls in personal care, generally when ‘less experienced’ staff were supporting their relative although on the whole they felt that personal care was done well. Another relative stated that they were ‘very happy’ with the care received by their family member. Several people told the Expert by Experience that they felt rushed when receiving help with their personal care and others felt they were not always listened to. One person in particular stated that this was difficult because in the past they had been able to manage their personal care but felt that it was assumed that they did not know how to manage. One service user told us that they had never had a problem with staff; they felt that ideally they should be able to reach a mutual understanding with staff as to how and when they liked things to be done. One person spoken with during the inspection told us that for two days they had wanted to ask their Team Leader a question but had not had the opportunity as staff were so busy; ‘You can’t blame her as she has to look after all of us.’ Some care workers spoken with talked about how they were aware some service users really needed time to talk to them but finding the time to do so was sometimes very difficult. Lack of quality time was an issue also highlighted by a relative who told us they were aware that their family member was ‘often really lonely’. This was seen to be especially the case when their key worker was not on duty; ‘X is often on their own especially at weekends’ All service users have a call bell in their rooms which they can use to summon assistance. Service users were asked by the Expert by Experience about the length of time they have to wait for their call-bell to be answered. People felt that this varied depending on staffing levels. Three people out of the six who met with the Expert by Experience said they had been incontinent because support had not arrived quickly enough to enable them to use the toilet when Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 21 they needed to. This issue was also raised by a relative in a survey who commented that care workers did not always take their family member to the toilet when she needed to go. They felt that this was more likely to occur at weekends or at times when her key worker or ‘cluster carers’ are not around; ‘X is often kept waiting’. We observed service users ringing their call bells to summon assistance twice during the evening. At 1900 hrs a member of staff was able to respond in four-and-a-half minutes. At 2000 hrs a member of staff was able to respond in one minute. Staff spoken with during the inspection reported that they were aware that there is sometimes a five minute delay before they can attend to people’s call-bells. The current call system in the home does not give a print-out of call response times but the manager stated that a new call system would be installed by the end of the year which would alert staff to people who have been waiting for more than a specified time. Discussion with care workers indicated that there are an increased number of people requiring support with eating and drinking. It was reported that in one apartment there are four people who require this support and in another apartment there are two people who need a lot of assistance and one person who requires some assistance. For the apartment which has four people with eating and drinking needs, an additional member of staff is allocated to stay on for thirty minutes at the end of their shift to offer support to meet this need so that there are two care workers to support four service users around a table. In another apartment, there is only one member of staff to support three people with varied needs. A member of staff spoken with stated that care workers do their best to make meal-times a sociable and positive experience for service users but it was difficult to see how a person-centred approach to eating and drinking could be fully achieved given staffing levels. Inspection of one person’s support plan showed that information about their bathing routine had been included. The service user told us ‘We’re allocated when we have baths. I have two a week. Bath days are Tuesday and Thursday mornings.’ We asked whether they would like to have a bath more often or at different times, to which the service user replied ‘I would but it’s one of those things isn’t it? If you were at home you would. I don’t suppose they’ve got the staff.’ A tour of one of the apartments indicated that on the wall in the ‘battery-charging room’ there was a chart of three people’s bath routines, two service users allocated to have baths three times a week and one service user allocated to have a bath twice a week. Information about people’s moving and handling needs was seen in people’s support plans. The ‘Minimal Handling of Persons Assessment Form’ was seen for one person. This detailed the techniques, equipment, constraints and actions required to support the individual with their mobility needs. Review dates on the document showed that it had been reviewed in July 2004, November 2004 and April 2005. There was no evidence to show that the plan had been reviewed since this time. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 22 Support plans showed that people are supported to access health care services as necessary to meet their needs with health care appointments documented. This was confirmed by care managers who have contact with the home with four out of five care managers indicating that people’s health care needs were always properly monitored and attended to by the service; ‘One permanent resident has ongoing needs for support with medical tests. The Grange have been great at providing this support’; ‘GP advice sought where necessary’; ‘Good communication with family and other agencies’. Two health care professionals told us that individuals’ health care needs are usually met by the service. On the day of the inspection, one service user had returned from a hospital stay earlier that day and had chosen to stay in their bedroom for the evening. Another service user returned from hospital during the evening accompanied by relatives. Although a member of staff was allocated to this apartment for the shift, they had needed to help assist on another apartment and therefore for more than twenty minutes the apartment was not staffed and people who lived in the apartment did not know where the member of staff was. People who live at the home have a lockable cabinet attached to the wall of their bedroom which is used to store their medication. Medication is supplied by a pharmacy. Medication administration record (MAR) charts, also printed by the pharmacy, were seen to be kept with people’s medication. One person’s medication was inspected. The MAR chart showed that medication had been signed for appropriately indicating that it had been given as prescribed. Risk assessment documentation around the administration of medication was seen in a sample of people’s support plans. For one person this stated ‘Medication is managed by staff’. However, there was no further information to state how medication should be administered to the person or their level of independence in doing so. Training in medication administration is in place for care workers. A member of staff spoken with indicated that they had received this training before being allowed to administer medication to service users. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 23 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place but improvements are needed to ensure that complaints and concerns are always responded to in a way that delivers positive outcomes for people. EVIDENCE: Out of eleven service users responding to the survey, three indicated that their care workers always listened and acted on what they said, six said that this was usually the case and two said this only happened sometimes. All service users who met with the Expert by Experience said that they knew how to go about raising their concerns or making a complaint through the home’s complaints procedure. One person told us that they had used the procedure to positive effect. Relatives responding to the survey told us that they knew how to make a complaint if necessary. Out of the four relatives who completed a survey, two told us that the home had always responded appropriately if they had raised concerns about care provision. The remaining two said that the home usually responded appropriately. Care managers told us in surveys that the home has responded appropriately if they or the person using the service have raised any concerns, one care manager stating that the manager of the home had been quick to respond to comments from a relative. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 24 The home’s complaints record was seen, this showing that four complaints have been made since the last inspection of the service. The progress of complaints is tracked through documentation in the home and quarterly returns are made to the organisation’s Regional Office so that senior managers are aware of issues being raised. It was noted that all four complaints made about the service were in connection with respite care issues. The Commission has received one complaint about the home in the past twelve months. The complaint was referred to us because the complainant had not received a timely acknowledgement or response from the home. The Registered Manager told us that complaints about respite care are directed to the manager of the respite unit at The Grange. However, the Registered Manager is responsible for ensuring that regulations and national minimum standards are met throughout the whole service and therefore must ensure that all complaints are responded to in a timely manner in line with the organisation’s policy. All care workers responding to the survey told us that they knew what action to take if a service user or relative had concerns about the home. One service user spoken with at the inspection told us that they had raised a particular concern with a Team Leader but was not sure if anything had been done about it. The service has introduced a record for documenting concerns which is kept in the manager’s office. The concern raised by the service user had not been documented. The home has told us in their Annual Quality Assurance Assessment that they have a policy on safeguarding adults and the prevention of abuse and a policy on whistle blowing, both of which have been reviewed in the past year. The home has also told us that there have been no safeguarding issues arising in the past twelve months that have required referral or investigation by statutory agencies. Discussion with the home’s Training and Development Officer indicated that all staff access training in abuse awareness during their induction programme and receive regular updates every two years. A member of staff spoken with confirmed that they had received this training. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 25 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home environment provides people with suitable facilities to meet their individual and shared needs. EVIDENCE: Service users’ living accommodation is divided into separate apartments housing up to five service users each. Four apartments are situated on the ground floor and one apartment, used mainly for people having respite stays, is situated on the first floor and is accessible by a lift and stairway. Each apartment has its own bathroom and kitchen facilities and a communal dining area. There is a central laundry facility. The home has been adapted to meet the needs of people with disabilities with doorways that are accessible to wheelchair users and automatic doors. A care manager who has contact with people who use the service told us in a survey that they felt the ‘four clusters in the residential unit appear to work well and give a more friendly / family unit environment for the individual’. People have been able to personalise Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 26 their bedrooms as they wish and the bedrooms seen were in good decorative order. One care manager visiting the home told us ‘The Grange is bright and airy with spacious rooms’. The home employs a person to take responsibility for the maintenance of the building. The home has told us in their Annual Quality Assurance Assessment that they have undertaken a programme of refurbishment in communal areas which has included door protection, new décor, pictures and curtains. It is suggested that the home continues this programme as it was felt that some carpets would benefit from being replaced and one service user spoken with felt that the home was ‘clean, but needs decorating’ in further areas. The home has told us in their Annual Quality Assurance Assessment that they are looking to replace the roof in the communal hallway of the building in the next twelve months. A requirement was made at the last inspection about the need for the home to review the security of the premises. The issue raised at the last inspection was that the main doors to the home open automatically allowing visitors access to the large reception area of the home which is not staffed. This was seen as presenting a potential security risk. The Registered Manager reported that the issue has been reviewed taking into account that a number of service users want the doors to automatically to allow them easy access and egress to and from the building as they wish. The current situation is that Team Leaders are responsible for locking the doors at 5pm each afternoon. Those service users who wish to go out after this time have access to key fobs which they can borrow and return as required which allows them to access the building as they wish. The Registered Manager was advised that some visitors to the home are still telling us that this is an area of concern for them and that the home must take appropriate steps to safeguard vulnerable adults living in the home. Therefore security arrangements should be kept under ongoing review to ensure that, while people are not restricted unnecessarily, people are also protected from harm and the home is a safe place to live. Out of eleven surveys received from people who use the service five told us that the home was always clean with the remaining people indicating that this was usually or sometimes the case. One person commented that ‘any spillages are dealt with very quickly’. The home employs domestic staff to clean the home and the home has told us that there are cleaning rotas and cleaning checklists to ensure that standards of cleaning are maintained. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 27 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from care workers who are well-trained. However, there are not always enough staff to meet people’s assessed needs and preferences which impacts on the quality of care they receive. The home’s recruitment procedures are not robust enough to ensure that they have all the information they need to make safe decisions. EVIDENCE: The service has a Training and Development Officer who works across the county co-ordinating training for all staff and implementing the organisation’s training plan. A comprehensive induction programme is in place which covers all aspects of mandatory training. The majority of staff responding to the survey told us that their induction covered what they needed to know very well. Discussion with the Training and Development Officer indicated that the service has a comprehensive computer system for identifying when people Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 28 require update training and to book people onto specialist training to meet the individual needs of people who use the service. Again, staff told us that this was something the service does well; ‘Training is very good’; ‘There is always plenty of scope for more training and bettering yourself in your career’. One person told us that they had asked for some specific training to equip them for their role but due to finances some training had been stopped. They also felt that due to staffing levels they were not always able to go on training. It is suggested that the home looks to remove any barriers that may exist to people accessing training. Half of the twelve staff responding to the survey indicated that they felt they did not always have the experience and knowledge to understand diversity issues, for example, age, gender, race, ethnicity, sexual orientation and faith. The Training and Development Officer confirmed that training in these areas is being rolled out by the organisation. The home has told us in their Annual Quality Assurance Assessment that they aim to involve service users in more areas of training delivery. Discussion took place with the Training and Development Officer around the greater use of experiential training within the home. She responded enthusiastically to this and agreed that this could be incorporated into the induction programme. The home has told us in their Annual Quality Assurance Assessment that out of forty-five permanent care staff, twenty have a National Vocational Qualification at Level 2 or above and nine are working towards this qualification. Following the last inspection in October 2006 a warning letter was issued to the provider with regards to staffing levels in the four apartments on the ground floor. Copies of the staff rota and discussion with the Registered Manager at the inspection indicated that the home generally has a minimum of eight staff on duty every morning and four in the evenings. The manager said that the last inspection had taken place during a period of significant staffing difficulty with two permanent care workers on long-term sick leave. He reported at this inspection that there had been very few occasions when staffing had fallen below four staff in the evenings for a total of twenty service users. This was confirmed by care workers. He was also able to show us graphical evidence that the home has reduced sick absence levels in the last year. Verbal and written feedback from some service users, their relatives and care workers indicated that staffing levels continue to be an issue in the home; ‘Most things are down to a lack of staff’ (service user); ‘If there was one thing I could wish for this home it is more staff’ (relative). One service user told us ‘In the morning there are two staff (on each unit) to do things…plenty of staff to get us up and going in the mornings. In the evenings, because we have a lot of people who need feeding a member of staff stays on until 5pm which is a good thing. It is later on in the evening when people are starting to get ready for bed when we need more help.’ Some staff spoken with indicated that there Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 29 are some evening shifts that go smoothly and the team ‘pull together’ and at those times staffing levels are ‘just about adequate’ to provide personal care although there are not enough staff to assist people with going out. However, on other shifts it was described as more difficult to meet people’s care needs especially if team-working was not as effective. Staff told us that thirteen out of twenty service users require two people to help them with moving and handling. Each apartment is staffed by one care worker in the evenings which means that they would need to request this support from a member of staff in another apartment. The Registered Manager told us at the inspection that they are hoping to be able to employ an additional member of staff in the evenings from April 2008. This is dependent on the home increasing their income as we were told that the home is already overspent on their staffing budget. The Registered Manager was asked at the time of the inspection if an additional member of staff could be employed earlier than April 2008 as it appeared from the feedback received that there had been very little positive change in the staffing situation and this was an area of concern. Following the inspection the Registered Manager e-mailed us to say that he had raised the issue with the General Manager and an additional member of staff would be recruited as soon as possible. We have asked for the manager to inform us when this is implemented. The Registered Manager talked about the need for the home to make staffing more flexible, for example, reviewing traditional shift patterns to ensure that there are more staff on duty at times of ‘peak’ needs. A member of staff spoken with indicated that some staff were doing this already and they would be commencing their early shift at 6am the next day as some service users needed to get up early. The manager told us that a team of bank staff have also been recruited to promote more flexibility within the staff team. A sample of three recruitment records for new staff was seen. These showed that checks with the Criminal Records’ Bureau were in place and there was proof of identity on file for each person. For one person, a full employment history was not clearly documented. For two people, there were two written references on file but for the third person there was only one reference. This was raised with the Care Supervisor at the time of the inspection who told us that the member of staff had collected it from the referee and was due to deliver it to the home. This individual was already working at the home. Care workers told us that they feel well-supported by their Team Leaders who are their main source of support and supervision; ‘I have a very good Team Leader who supports her staff well’. However, people generally felt that there was less positive communication with management; ‘I feel management don’t praise staff enough’; ‘We do not feel valued by management’ ; ‘Communication…could be better – there should be more regular staff meetings with all staff not just care staff’; ‘Make the staff feel appreciated’; ‘The Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 30 management could be more supportive’; ‘The manager could sort out problems better with staff’; ‘Very rarely does the manager give support especially if there are problems with service users’; ‘Not enough communication’. It is recommended that the manager reviews these issues to ensure that people feel well-supported by the management team and that good communication is promoted. The manager told us that he was due to undertake a two-day ‘Communication Training for Managers’ course in the near future as part of a national programme being rolled out by Leonard Cheshire for all managers. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 31 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a management structure in place with clear lines of accountability. However, a more prompt response to areas of concern is needed to evidence that people who use the service benefit from a service that is run in their best interests. EVIDENCE: A staffing structure is in place that offers clear lines of management and accountability. The Registered Manager of the home has several years’ experience in the post and has a NVQ Level 4 in Care and Registered Manager’s Award. The manager is supported by a Care Supervisor and Team Leaders who have responsibility for supervising a large team of Support Workers. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 32 A warning letter with regards to staffing levels was issued to the home on 31st October 2006 following the last inspection of the service. Although the Registered Manager has told us of the steps the home has taken in the past year to ensure the home is adequately staffed, feedback from people who use the service and those who have contact with them indicated that there has been little change in outcomes for service users. Until this is fully addressed, this continues to be an area of concern for the Commission as it does not show that the home is being fully responsive to what we told them at the last inspection which was based on what people who use the service were telling us. Although the manager has recently told us that staffing levels will be increased in the evenings as soon as practicable, it has taken a year for the home to do this since the warning letter was issued. A requirement is being made for the service to provide evidence that the revised staffing levels will meet people’s assessed needs. The organisation carries out an annual survey of service users to ascertain their satisfaction with the care they receive. A report is then published based on the findings. The last survey was carried out in November 2006 looking at issues such as respect and dignity, choice and decision-making, delivery of personal care, support with activities, food provision, individual service plans, raising concerns and the role of volunteers. Thirteen surveys out of twentyone were returned and responses summarised in the report were generally very positive. The service may wish to look at how they could obtain increased levels of feedback, possibly by involving independent advocates to help people with completing questionnaires or using alternative methods of communication where necessary, to enable as many people as possible to have their say. It is not clear how the home surveys relatives of service users and external stakeholders such as people’s care managers and health care professionals. They may wish to do this to obtain the perspective of others who visit the service. A sample of fire safety records were examined. A fire risk assessment was in place which had been carried out jointly by the Registered Manager and Care Supervisor. The Care Supervisor reported that an external fire safety company had been commissioned to undertake a full fire risk assessment in the near future. Weekly records of tests on the alarm system and automatic door release mechanisms were in place and up-to-date. Emergency lighting is also tested on a monthly basis although records showed a gap in September. Fire drills have been recorded as taking place in February and August 2007. The time of the drill, names of staff, service users and visitors present and the time taken to evacuate had been recorded. Discussion with the Care Supervisor indicated that they aim to do a practice evacuation every six months. It was discussed that it is important that as many service users and staff as possible should have the opportunity to participate in a practice evacuation in the course of a year and therefore the home should consider how Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 33 they achieve this. In addition, as both fire drills recorded as occurring this year were during day-time hours (1140 hrs and 1420 hrs), the home should consider doing fire drills at other times of day including when staffing levels are reduced, for example, in the evenings and at weekends. Staff training records showed that mandatory training in fire awareness, infection control, food handling, moving and handling and first aid is carried out as part of their induction programme and updates are arranged as necessary. Updates in fire safety training are carried out by staff who are appointed ‘Fire Marshals’ in the home. This has been recorded on individual fire safety records so that it is easy to see when each person’s last training session was carried out. The Care Supervisor confirmed that update training for Fire Marshals is carried out every three years by the organisation’s Regional Health and Safety Officer. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 34 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 3 X X 2 X Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 35 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 YA33 Regulation 18(1)(a) Requirement The registered persons must provide suitable evidence that there are sufficient numbers of suitably qualified, competent and experienced staff to support service users’ assessed needs at all times. This requirement refers to the home’s capacity to meet individuals’ personal care, emotional and social and leisure needs so that they experience positive outcomes. This requirement is repeated from the last inspection of the service as the previous timescale of 15/11/06 has not been fully met. 2. YA34 19 The registered person must ensure that there is full and satisfactory information available in relation to all persons working in the care home in accordance with Schedule 2 of the Regulations. 14/12/07 Timescale for action 31/12/07 Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 36 This helps ensure that people who use the service are fully protected by the people employed to provide their care. 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. Refer to Standard YA6 YA9 Good Practice Recommendations The home should ensure that people’s individual plans describe how the service will assist them in meeting their aspirations and achieving their goals. The home should ensure that all risk assessments are reviewed on a regular basis so that they continue to contain valid information and meet the changing needs of individuals. People’s support plans should give information about how they need and prefer care workers to administer their medication. The home should ensure that people who complain about the service receive a prompt response in line with the organisation’s complaints procedure. The home’s concerns book should be easily accessible to staff and service users to allow all concerns to be documented at the time they are raised. This will help ensure that there is a clear record of concerns raised and that people receive a timely response. The home should ensure that communication systems between management and staff are reviewed to ensure that people feel supported and have confidence in the way issues are dealt with. Fire drills and practice evacuations should take place at sufficiently regular intervals to ensure that all staff and people who use the service have the opportunity to participate. Fire drills should take place at times at times when staffing levels are reduced, for example, in the evenings and weekends. Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 37 3. 4. YA20 YA22 5. YA36 6. YA42 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Grange (The) DS0000004086.V351048.R01.S.doc Version 5.2 Page 38 - 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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