Inspection on 23/11/05 for The Grange

This inspection was carried out on 23rd November 2005.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Grange 17/10/06

The Grange 16/06/05

The Grange 13/01/05

The Grange 22/09/04

The Grange 26/03/04

The Grange 12/09/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Grange 15 Holmwood Drive Tuffley Gloucester Glos GL4 0PS Lead Inspector Mr Paul Chapman Unannounced Inspection 10:00 23 November 2005 rd The Grange DS0000016664.V260003.R01.S.doc Version 5.0 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 The Grange DS0000016664.V260003.R01.S.doc Version 5.0 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. The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Grange Address 15 Holmwood Drive Tuffley Gloucester Glos GL4 0PS 01452 300025 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) Mr Rodney Wayne Correia Susan Ann McQuire Care Home 9 Category(ies) of Learning disability (9) registration, with number of places The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered manager must complete her NVQ 4 in management by February 2006 The registered manager must complete her NVQ 4 in Care by February 2006 16th June 2005 Date of last inspection Brief Description of the Service: The Grange is a large detached Victorian house situated in a quiet residential area approximately three miles from the centre of Gloucester. The home offers residential care for up to nine adults with Learning Disabilities who from time to time display some challenging behaviours. Residential accommodation is provided on two floors, with three ground floor bedrooms and six first floor bedrooms. The ground floor of the property provides a Lounge, dining room, kitchen, laundry, conservatory, staff office, the communal bathroom and toilets. On the first floor in addition to the bedrooms there are two bathrooms, and an office. Outside there is a fenced garden/lawn area at the rear of the building, car parking area and garage/outbuilding. At the front there is a small garden area, with trees and shrubs. The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started at 1030am on the morning of the 23rd November 2005 and the inspection was completed over a period 1 hour and 45 minutes. The manager was present during the inspection. The inspection focused on the home’s progress towards meeting the requirements of the previous announced inspection. In addition to this the inspector completed a tour of the premises. A group of the service users returned to the home during the inspection and the inspector sat and spoke with them. For a more comprehensive overview of the service provided at the home this report should be read in conjunction with the report produced for the announced inspection dated 16/06/05. What the service does well: What has improved since the last inspection? The manager is maintaining their improvement strategy ensuring the service users needs are identified and met by the staff team or other professionals. The downstairs bathroom has been re-fitted with good quality fittings and fixtures. The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 6 Review of the home’s complaints procedure with the service users and their advocates should empower them to use the procedure in the future if they need to. 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 Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 7 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 The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were inspected on this occasion. No new service users have been admitted to the home since the previous inspection. The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: A requirement of the previous inspection was for the manager to write a care plan for the service user that travels independently. This had not been completed and the inspector explained the requirement in more detail to the manager. The plan should identify what steps were completed by the staff to ensure that the service user was going to be safe while they were travelling independently. Another requirement was for the manager to develop a missing persons protocol for this service user when they were travelling independently. This protocol has been written and available for examination at this inspection. It was seen to minimise the risk to the service user and give the staff clear instructions on the actions they should take. The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 EVIDENCE: The inspector spoke to a group of the service users who talked about some of the activities and a holiday they had been on. All of the service users appeared happy and contented at the time of the inspection. In discussion with the manager they spoke about a fireworks display organised by the owner of the home in November and the Christmas pantomime that has been arranged for December. A requirement of the previous inspection was for the actual meals consumed by the service users to be recorded. The menu book was examined and records appeared to be comprehensive. The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Medication record sheets must be completed consistently to ensure the risks to the service users are minimised. EVIDENCE: The previous inspection identified some gaps in the medication administration where staff had not signed, or completed the record sheets appropriately with a letter corresponding to the key/procedure. Examination of the previous months sheets showed that the number of “gaps” had decreased but there were still some present. This was brought to the attention of the manager. The manager must monitor these sheets regularly and where they identify the gaps the appropriate actions must be taken to rectify these errors with the staff responsible. The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The complaints procedure has been explained to all of the service users which should empower them to make their views heard if they are unhappy with anything. EVIDENCE: A recommendation of the previous inspection was for the manager to explain the complaints procedure to all of the service users. This has been completed with the service users or their advocates signing a document to confirm the process has been completed. The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 30 The manager must ensure that the service users privacy and dignity is respected at all times. The home is clean and tidy minimising potential risks to the service users. EVIDENCE: A tour of the premises was completed with the manager. All of the communal areas were seen to be clean and tidy with no offensive odours. The decoration was finished to a high standard. Since the previous inspection the downstairs bathroom has been re-fitted and has been decorated to a high standard with good quality fixtures and fittings. Two of the service users have swapped bedrooms since the previous inspection. Both of the rooms have been decorated, and the service users have been involved in completing this. One of the bedrooms did not have any curtains, the manager explained that this was due to the behaviour the service user displays (pulling the curtains down). The manager stated that they had plans to put curtains back up. A requirement of this report is that the manager must have “ mirrored privacy film” put on the windows as the home’s nextThe Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 14 door neighbour overlooks the service user’s bedroom. The manager stated that they would put net curtains up after the inspection was completed. All of the other bedrooms visited were seen to be nicely decorated and personalised by the people living in them. The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were inspected on this occasion. The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 EVIDENCE: The manager is currently completing an NVQ level 4 in management. This was a condition of their registration. The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Grange Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X X X DS0000016664.V260003.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Timescale for action 19/12/05 2. YA25 12(4) a The manager must monitor the medication recording regularly. Where gaps are identified appropriate action must be taken with the staff responsible for the shortfall. The manager must fit “privacy 19/12/05 film” to the bedroom window of the service user who pulls their curtains down. This is to ensure that at no time their privacy and dignity is compromised. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Grange DS0000016664.V260003.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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