Inspection on 29/02/08 for The Grange

This inspection was carried out on 29th February 2008.

CSCI found this care home to be providing an Adequate service.

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

The Grange 20/07/09

The Grange 23/02/09

The Grange 12/07/07

The Grange 06/12/06

The Grange 30/09/05

The Grange 13/06/05

The Grange 21/10/04

The Grange 19/04/04

The Grange 14/01/04

The Grange 10/11/03

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

CARE HOMES FOR OLDER PEOPLE The Grange The Grange Ratcliffe Highway St Mary Hoo Rochester Kent ME3 8RJ Lead Inspector Chris Woolf Unannounced Inspection 29th February 2008 09:10 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 The Grange DS0000029055.V358866.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. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Grange Address The Grange Ratcliffe Highway St Mary Hoo Rochester Kent ME3 8RJ 01634 270674 01634 270674 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 Henry Alfred James Holloway Post Vacant Care Home 10 Category(ies) of Dementia - over 65 years of age (10) registration, with number of places The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th October 2007 Brief Description of the Service: The Grange is located in a rural area with few local amenities. To the front of the property there is a circular drive and a paved area, offering ample parking. To the rear there is a large garden mostly laid to lawn, with a raised patio area. The home occupies detached premises with accommodation on two floors. There is a single person lift between the two floors. There are 8 single rooms and 1 double bedroom. 2 of the single rooms and the double room have ensuite facilities. There are call bells in bedrooms, bathrooms and toilets. The staff provide 24-hour cover working a rota, there is one waking night staff on duty at night supported by a member of staff on call to provide support in the event of an emergency or additional support being needed. The current fees for the service at the time of the visit range from £450 - £500 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. There is no current e-mail address for the home. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The information for this report has been gained from information gained prior to the date of the inspection; comment cards received from 3 relatives of clients living in the home; and a site visit to the home. The site visit was unannounced. This means that neither the staff nor the residents knew that we (the Commission) were intending to visit. The site visit lasted 6 hours and 20 minutes. During the site visit we spoke with all of the clients, some in passing and most during longer conversations. We also spoke with the deputy manager who assisted us throughout the day, and with the other staff on duty. We had a tour of the building. Our observations included the way in which the staff interacted with the clients; a meal being cooked and served; and administration and storage of medication. We examined a selection of records including client care plans, staff recruitment files, staff training records and rotas, medication records, and a variety of health and safety related records. Currently this home has no registered manager. The last manager left the service in December 2007, and the provider is actively recruiting for a new registered manager. In the meantime the provider has appointed the deputy manager as Acting Manager and this is the person referred to throughout the report. She is doing a good job of ‘holding the fort’. Since taking over the running of the home she has done a lot of work towards meeting the requirements of previous inspections. The people who use this service are referred to in the home as ‘clients’ and this is the term used to identify them throughout this report. What the service does well: The home has a friendly, welcoming, family type atmosphere. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 6 Client’s friends and family are made welcome in the home. One relative comment card said, ‘They treat myself and my family as if they had known us for many years. I cannot fault this home it’s the best’. There is a dedicated staff team who give a good quality of care to the clients. A relative comment card stated, ‘The personal care is brilliant. Every member of staff understands each of the resident’s personalities and needs and they care for them in a very compassionate way. The décor maybe shabby but I feel the TLC they receive far outweighs the décor. Each member of staff in my opinion goes over and above their normal duties’. A general comment received from a visitor said, ‘I feel blessed to have found a place where mum can live her life happy. She is a different person since moving to The Grange and I only have them to thank for her improvement in her health and mental state’. A resident said, “It was a godsend coming here”. What has improved since the last inspection? The requirements from the last inspection have either been met or are in the process of being addressed. A draft revised statement of purpose and service user guide have been produced and has been seen by us. A start has been made on improving care plans and 3 of the 9 clients now have new style plans in use. Medication practices are greatly improved. Meals in the home have improved and a nutritionalist has approved the revised menus. There are no longer any offensive odours in the home and a start has been made on improving the décor and maintenance. The home now has robust policies for the recruitment of staff. The registered person now carries out regular visits and these are documented as required by Regulation 26. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 7 Health and safety hazards to clients have been addressed and minimised. 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. The Grange DS0000029055.V358866.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 The Grange DS0000029055.V358866.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 & 4 Standard 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients needs are assessed and are only admitted if they and the home are confident of these needs being met EVIDENCE: The home has recently updated their statement of purpose and service user guide as required on the last report. A copy of the draft documents have been seen by us and the final printed documents should be available within a short time. A relative comment card stated, ‘My mother has been at the home for only 5 weeks. I have been given information on all aspects i.e. complaints etc.’ The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 10 There have been no admissions to the home since the recent change in management. However the acting manager now has a very thorough preadmission assessment form to use and understands the process. The new form includes holistic person-centred information on all aspects of the clients needs. The current admission policy is that if the client has a care manager a care plan is initially obtained from the relevant social services. The acting manager will then go out to visit the prospective client and complete the assessment form to ensure that the home can meet the clients needs. The prospective client is invited to visit the home for an all day or overnight stay. The acting manager confirmed that the home would not accept a client unless they are confident that they can meet their needs. This home caters for clients with dementia and the staff have received training in this subject. This home does not offer an intermediate care service. This is a specialised service with intense rehabilitation in a dedicated unit aimed at enabling clients to return to their own homes. The Grange DS0000029055.V358866.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, & 10Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Clients’ health and personal care needs are met by the home supported by health care professionals. Clients are treated with dignity. Delays in completion of person centred care plans could compromise client care. EVIDENCE: There was a requirement on the last report regarding service user plans. Since taking over the running of the home the acting manager has made a good start on this, and has worked hard to complete new holistic and person centred care plans. So far new care plans are in place for 3 of the clients. The remainder of care plans are currently not satisfactory and could be considered confusing. A requirement has been made that new service user plans should be completed for the remainder of the clients. It is recognised that these take some time to complete and the timescale set reflects this. During the time the The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 12 last manager was in position regular reviews of care plans were not taking place and therefore a requirement has also been made that care plans should be regularly reviewed and that the clients or their representatives should be involved in these reviews. Client’s health and personal care needs are being met by the staff of the home supported by health care professionals. The new care plans include risk assessments for tissue viability. Any incident of pressure sores is reported to the district nurses who give advice, treatment, and provide necessary equipment. Advice is also sought from the district nurses for continence problems. Nutritional assessments are carried out and weights are monitored on a monthly basis. The home has arranged for someone to visit regularly to do exercises with the clients. Clients have contact with a variety of health care professionals e.g. Doctors, nurses, optician, chiropodist, etc. A resident said, “they get the doctor when we need one”. Relative comment cards included, ‘personal care is great even to painting finger nails etc’, and ‘I cannot praise this place enough it is full of love and the care is A , nothing is too much trouble’. The report of the last inspection included a detailed requirement on medication. The home has addressed all of the issues raised. They now have medication policies in place. The recording of receipt, administration, and disposal of drugs has been improved. The recording and storage of controlled drugs has been addressed. A medication trolley has been purchased for transporting drugs around the home. The person administering medication checks that the correct medication is taken before signing for it. Staff who administer medication have been received updated training. Clients in the home are treated with dignity and their right to privacy is respected. Clients said, “they treat us with dignity”, “there is never any fuss if we have an accident”, and “the staff treat us as individuals”. Visitor comment cards included, ‘She (client) is always as is everyone else, dressed nice, always clean and tidy’, and ‘My mother is treated with dignity at all times. The staff are always polite and caring they always have time or should I say make time to sit with all residents, nothing is too much trouble for any of them. I have never been to a care home which offers such love and attention to all concerned’. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 13 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, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients are encouraged to lead a lifestyle that meets their needs and preferences with regular contact with relatives and friends; they are encouraged to make choices; and are given a wholesome and nutritious diet. EVIDENCE: The home organises a variety of activities for the clients to keep them stimulated and motivated. These activities normally take place in the afternoon and a record is kept of who joins in and who declines. Clients said, ““We have a sing song, people come from the church”, “I like darts”, “I like Bingo”, and “We play skittles and quoits, we do something most days”. During the morning of the site visit clients were observed watching television, listening and singing along with music, and generally chatting with one another. One client explained how he likes to go out into the garden when the The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 14 weather is good enough. In the summer there are regular trips out, often to The Friary at Aylesford to feed the ducks and have tea out. A visiting professional holds hour-long exercise and motivation session monthly. Visiting entertainers include Old Time Music Hall shows, and a visiting singer. The staff of the home supports clients who wish to follow their religious or cultural beliefs and visiting clergy are arranged as required by individual clients. Services are also held on all of the major Christian feast days for those clients who wish to join in. Clients are encouraged to maintain contact with their families and friends. Clients said, “They make visitors welcome”, and ”, “I’m going out with my son on Sunday”. Staff said, “The relatives are very supportive”, “Relatives make themselves cups of tea”, and “Relatives often offer to organise things for us”. Relative comment cards included, ‘They are also very kind to relatives’, and ‘I ring my mum every morning and most mornings they put her on the telephone to speak to me, and they always tell her I have called’. Clients have choices in all aspects of their daily lives as far as they are able. Two clients have their own telephone lines; others are contacted via the homes telephone. Each client has a copy of their ‘rights’ pinned up in their room and there is a copy on display in the hallway. A relative comment card stated, ‘The residents are given choice’ There was a requirement on the last report ‘The registered person shall provide, in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared’. Since that time the home has held a meeting with the clients to discuss meals. Menus have been reviewed and a nutritionalist has approved the new menus. Residents said, “lunch was nice”, “the food is good”, “There is always fruit here”, and “Food is not bad, excellent”. A member of staff said, “We like to do the cooking ourselves”. A visitor comment card said, ‘The food is great’. The staff are very good at ensuring clients always have plenty of fluids. Clients said, “They give us plenty of drinks”, and “They complain if I don’t drink enough”. A visitor comment card stated, ‘always has a cup of drink by her side which is re-filled as soon as it is empty’. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 15 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, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients and their relatives know that their complaints and concerns will be listened to and acted upon and that they will be protected from abuse. EVIDENCE: The home has a clear complaints policy, and a copy is on display in the hallway. There have been no complaints recorded since the last inspection. A relative comment card included the statement, ‘I have been informed about how to complain’. There have been no adult protection alerts on the home since the last inspection. The home has policies on Abuse and Whistleblowing. All staff have received training in the Protection of Vulnerable Adults. All current staff have had an enhanced disclosure undertaken by the Criminal Records Bureau which includes a check of the Protection of Vulnerable Adults register. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Clients live in a home that is homely and clean but which needs some attention in places to address its shabby appearance. EVIDENCE: Clients live in a home that is homely and comfortable although a little ‘shabby and tired’ in places. There is a lift to provide access to the first floor. At the rear of the property are a patio area and a garden that is mainly laid to lawn. One client said, “I like to get out into the garden when the weather is nice enough”. A relative comment card included, ‘The Grange is a wonderful The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 17 home. The place is a little shabby but I would rather it be as it is than clinical with no care’. There was a requirement on the last report about the repair and maintenance of the home. Since that time a variety of improvements have been made including refurbishment of the bathroom and some decoration. However there are still some areas that need attention, in particular the doorframes and skirting boards, a damaged wall in one client’s bedroom, and a splash-back needed in another bedroom. History has shown us that maintenance in the home tends to be reactive rather than proactive and a requirement has therefore been made regarding the items mentioned. A staff member said, “The owner has improved the décor”. Visitor comment cards answered the question about how the service could improve with, ‘money to spend on refurbishing’, and ‘Maybe a little paint and tidy up but it is clean and homely’. The home has a large and airy lounge/dining room and there is ramped access to the patio and garden areas. A staff member said, “The clients have all brought in their own armchairs for the lounge”. Clients bedrooms have all been personalised to meet their own needs and tastes. Clients said, “I have got my own room, its not bad”, “I have got a T.V.”, and “I have got my own CD player, I like classical music”. There are two rooms suitable for shared occupancy and at present two sisters share one of these rooms. Privacy curtains were provided but have been removed at the request of the occupants. The home is clean, and on the day of the inspection site visit there were no unpleasant smells. Clients said, “It always looks clean”, and “There are no smells”. A relative comment card stated, ‘there are no odours only cooking’. The home has the facilities to ensure that any soiled linen can be washed appropriately. Staff have access to personal protective equipment, hand washing facilities, and anti-bacterial gel hand cleanser. It is recommended that the home carries out an Infection Control Audit using the latest guidelines, and implements any shortfalls that may be identified. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 18 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, & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Clients are cared for by a very caring staff team but out of date training could compromise their safety EVIDENCE: The current staffing levels in the home is sufficient to meet the needs of the client current group but should be kept under continual review. At night there is only one member of staff awake and on duty but there is always another member of staff living in the vicinity who is on call. The home is currently advertising for a cleaner and for an additional night carer. 80 of the current staff team have achieved NVQ at Level 2 or above. Staff comments included, “I’ve done NVQ 2”, and “I liked doing the NVQ, I have recently finished it”. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 19 There have been no new staff recruited since the recent change in management. However the acting manager explained clearly the process for recruitment and confirmed that no new member of staff would be employed until a satisfactory check of the Protection of Vulnerable Adults Register and 2 written references were received. Staff files viewed all contained Criminal Record Bureau enhanced disclosures. Current staff files need to be updated to ensure that they comply with amendments made to Schedule 2 of the Care Homes Regulations 2001, particularly with regard to full employment history and references for staff who have been working in the home for a number of years. A Recommendation has been made regarding this. Although most staff have had training over the years in the mandatory subjects, the acting manager has identified that much of this is now out of date. She has already started to make arrangements for all staff to be updated. All but the newest 2 members of staff have received in depth training in Dementia. Training that has taken place recently includes Protection of Vulnerable Adults, and updates in Medication. The home has a system of induction training in place for new staff, which meets with the Skills for Care specifications. A staff member said, “I have done so many courses since I came here”. Some very positive comments were received about the staff. Clients said, “Staff are a wonderful group, they do a wonderful job”, “the staff are the tops”, “They are all very kind”, and “They understand”. Relative comment cards included, ‘The staff are 1st class, they treat everyone like a family member, if someone needs something they are there straight away’, ‘Mum has not been this happy for a few years she said she always has company and that the girls cant do enough for her’, and ‘Each member of staff in my opinion goes over and above their normal duties’. General comments from staff included, “I enjoy it”, and “We all get very involved”. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 20 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, & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs a suitably qualified and competent manager to ensure that it is being run in the best interests of the clients. Out of date staff training could compromise the health, safety and welfare of clients and staff. EVIDENCE: There was a requirement on the last report that the registered provider shall appoint an individual to manage the care home who has the skills, experience and qualifications to ensure that the home is managed to a good standard. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 21 Although a manager was recruited she has since left and the home does not have a Registered Manager. The provider is currently actively recruiting for a properly trained and experienced manager for the home. However the previous requirement has been repeated on this report with a new timescale. In the meantime the Deputy Manager, who has worked in the home for the past 10 years and is trained to NVQ Level 2, is running the home and holding things together until a new manager can be appointed. The acting manager is doing a good job of trying to address shortcomings in the home and of keeping the staff together. Staff commented, “If it wasn’t for xxx (acting manager) we would not be here”, “xxx (acting manager) is very supportive”, and “The last manager gave us no support”. The acting manager confirmed that the provider gives her support and said, “The owner is at the end of the phone every day. He has become far more supportive”. The home has some Quality Assurance systems in place but these need to be expanded. The registered provider now makes regular visits as required on the last report. These visits, which are documented, include talking to clients and staff, and checking on the environment. A resident commented, “I mention things and they get things for me. They have recently got me a nice big bed”. Resident meetings are also being held and the minutes of a meeting to discuss menus was viewed. There are health and safety audits in place but few other formal audits take place. Questionnaires to stakeholders are not being carried out on an annual basis as required. A requirement has been made about improving the homes Quality Assurance systems. The home has robust procedures in place for dealing with client’s monies. Receipts are kept and all transactions are documented and double signed. All of the home’s policies and procedures have been reviewed during the past year. The health, safety and welfare of staff and service users could be compromised by the shortfalls in mandatory training. As mentioned in the section on staffing this has already been identified by the Acting Manager and she has the situation in hand. Health and safety monitoring checklists are now in place and being completed regularly. There is a health and safety action plan with planned and completed dates. A safety awareness-training course is being arranged for all staff responsible for Health and Safety, and all staff have received handbooks/questionnaires on Health and Safety. Fire risk assessments were completed in 2007. The certificates for safety compliance viewed were all in date. Accident records are appropriate. The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 (1) Requirement New person centred service user plans should be completed for the clients for whom these are not yet in place. All care plans should be regularly reviewed and the clients or their representatives should be involved in these reviews. The premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. In that the damaged bedroom wall should be repaired and the doorways and skirting boards throughout the home should be repaired and decorated. The registered person shall, ensure that the mandatory training for all staff is up to date and relevant. The registered provider shall appoint an individual to manage the care home who has the skills, experience and qualifications to ensure that the home is managed to a good standard. DS0000029055.V358866.R01.S.doc Timescale for action 30/04/08 2. OP7 15 (2) (ad) 23(2) 30/04/08 3. OP19 30/04/08 4. OP28 18(1) 30/04/08 5. OP31 8 (1) 31/05/08 The Grange Version 5.2 Page 24 6. OP33 24 (1) & (5) The provider should put in place additional formal quality assurance strategies to ensure that stakeholders’ views are sought and taken into account and that all aspects of the care of the service users are regularly audited. 30/05/08 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 OP26 OP29 Good Practice Recommendations It is recommended that the home carries out an Infection Control Audit and implements any shortfalls that may be identified. All staff files should be updated to ensure they comply with the requirements of Schedule 2 of the Care Homes Regulations 2001 The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 The Grange DS0000029055.V358866.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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