Inspection on 03/03/05 for The Grange

Care Homes For Adults (18 – 65)The GrangeRedworth Road Shildon Durham DL4 2JTAnnounced Inspection2nd March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment The Grange Address The Grange, Redworth Road, Shildon, Durham, DL4 2JT Email address Tel No: 01388 772115 Fax No: 01388 772115Name of registered provider(s)/company (if applicable) Highlea Homes Limited Name of registered manager (if applicable) Julie Cowens Type of registration Care Home No. of places registered (if applicable) 19Category(ies) of registration, with (number of places) Learning disability (5), Physical disability (13), Physical disability over 65 years of age (1) Registration number B040000252 Date first registered 11th June 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 5th January 2005 Yes YES 19/10/04 If Yes refer to Part CThe GrangePage 1 Date of inspection visit – Announced Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 33rd March 2005 09:15 am Belinda ParkerID Code160612Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionJulie Cowens, Michelle CatorThe GrangePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 – 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s AgreementThe GrangePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of The Grange. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.The GrangePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The Grange is registered for 19 adults (13 physically disabled, 5 with a learning disability and 1 older person with a physical disability). The home is situated on the edge of town; it has been attractively adapted from an old school. Service users have ground floor accommodation that is suitable and accessible for people with mobility problems. The grounds are pleasant and there is on-site parking. It is owned by Highlea Homes Ltd.The GrangePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspector’s Summary (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) On the day of the inspection the management and staff were welcoming. The atmosphere in the home was relaxed and friendly and service users were observed to be moving freely around the communal areas. It was observed that service users were participating in a range of activities of their choice. Since the last inspection staffing levels have been improved with the appointment of ancillary staff, which enables care staff to devote more time to care of service users. Discussion with service users and relatives during the inspection and comment cards received prior to the inspection highlighted that satisfaction levels were high with reference to the care service delivery and standard of accommodation. Records and documents viewed during the inspection were accurate and up to date. Overall this was a positive inspection with many areas exceeding the National Minimum Standards. Choice of Home (standards 1 – 5) The only standard assessed in this section was met. Since the last inspection the process of acquiring pre-admission information from the Care Manager had improved. Individual Needs and Choices (Standards 6 – 10) Two standards assessed in this section was met. Since the last inspection there had been further development with reference to identifying and documenting risks for individual service users. Lifestyle (Standards 11 – 17) Three standards assessed in this section were met. Since the last inspection the home now employs an activities co-ordinator. Service users spoke positively about maintaining links with their family and friends in the community. The standard of choice and quality of the food served in the home was good, a cook has now been employed by the home since the last inspection. Personal and Healthcare Support (Standards 18 – 21) Two standards assessed in this section were met. An appropriate policy and procedure was in place for the safe handling of medicines and death and dying in the home.The GrangePage 6 Concerns, Complaints and Protection (Standards 22 – 23) No standards were assessed in this section at this inspection (Standards met at the previous inspection). Environment (Standards 24 – 30) Four of the six standards assessed in this section exceeded the National Minimum Standards. The home provides a high standard of well maintained and comfortable accommodation for service users. Staffing (Standards 31 – 36) All six standards assessed in this section were met. Since the last inspection the home now employs ancillary staff, enabling care staff to devote more time to meeting service users needs. Staff records examined showed that the home follows a thorough recruitment process to ensure the protection of service users. Conduct and Management of the Home (Standards 37 – 43) Since the last inspection a new manager has been appointed, who is experienced and has achieved the Registered Managers Award. Evidence was available to show the home is financially viable and a current business plan was in place.The GrangePage 7 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this reportThe GrangePage 8 Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other enter details here ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES NO YES YES NO NO NO YES YES YES NO YES YES YES YES NO YES NO YES 8 2 8 YES YES YES YES 15 X 03/03/05 9:15 7The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded The Grange (Commendable) Page 9 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met(No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable.The GrangePage 10 Choice of HomeThe intended outcomes for the following set of standards are: • • • • • Prospective service users have the information they need to make an informed choice about where to live. Prospective service users’ individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 – 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users’ guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Hairdressing, activities and transport 0 Key findings/Evidence Standard met? This standard was not assessed in depth at this inspection. Since the last inspection evidence was available to show that the Statement of Purpose and Service User Guide had been up dated to reflect the change in management.Standard 2 (2.1 – 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? At the last inspection it was highlighted that pre-assessment information was not always available form the Care Manager prior to admission to the home. The manager said this has been an ongoing problem, which she has discussed with the Care Manager responsible for placing any prospective service user. Care plans examined for service users recently admitted to the home contained an up to date pre-admission assessment from the Care Manager and a comprehensive home assessment. A relative spoken to during the inspection said she and her family had been involved in the assessment process prior to the admission of her relative.The GrangePage 11 Standard 3 (3.1 - 3.10) The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.The GrangePage 12 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: • • • • • 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.Standard 6 (6.1 – 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Since the last inspection the section in the care plan with reference to risk management has been further developed to include a risk assessment in line with the individual needs of the service user where a risk has been identified. Evidence was available to show that service users or their representative sign as to their agreement with the care plan. A relative spoken to said she was involved in the review process and was able to put forward her views on the care service being delivered to her relative.Standard 7 (7.1 – 7.7) Staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.The GrangePage 13 Standard 8 (8.1 – 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 9 (9.1 – 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the home’s risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Since the last inspection this area has been further developed and meets the standard (Refer to standard 6).Standard 10 (10.1 – 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.The GrangePage 14 LifestyleThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 11 (11.1 – 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 12 (12.1 – 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.The GrangePage 15 Standard 13 (13.1 – 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 14 (14.1 – 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Since the last inspection the home has appointed a designated activities co-ordinator (16hrs per week). During the inspection it was observed that several service users were participating in craft activities. Staff interviewed said they assist with activities but are now able to denote more time to caring for service users following the appointment of the activities co-ordinator.Standard 15 (15.1 – 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The manager said service users are encouraged to maintain family/friends links in the community. Key workers support service users use the pay phone and to write letters if requested to do so. A relative spoken to said she is always made welcome by the staff when she visits. A service user said his relative visits regularly and he maintains contact with other family members.Standard 16 (16.1 – 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.The GrangePage 16 Standard 17 (17.1 – 17.9) The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Evidence was available to show that the home provided a varied 4-week cyclical menu, which offered alternatives to the main choice. The manager said service users can eat in the dining room or in their own room if they so wish. During the inspection it was observed that service users were having their lunch in a relaxed and unhurried atmosphere. Sandwiches samples during the inspection were fresh and tasty. The manager said all staff have completed the Focus on Food course and arrangements are being made for senior staff to commence the advanced course when available. Service users spoken to were positive towards the choice and quality of food served in the home. Care plans contained evidence to show that a nutritional assessment had been carried out.The GrangePage 17 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: • • • • 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.Standard 18 (18.1 – 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users’ privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 19 (19.1 – 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence This standard was not assessed at this inspection. Standard met? XX 0The GrangePage 18 Standard 20 (20.1 – 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? A medication policy and procedure was in place. All staff responsible for administration of medication has completed the Safe Handling of Medicines course. All documentation with reference to administration, receipt and return of medicines was current and up to date. A random audit of Controlled drugs was found to be accurate and recorded appropriately. Service users care plans contained an assessment for self-administration of medication. There were no service users in the home at present that administered their own medication. Staff were aware to retain medication in the home for a period of seven days following the death of a service users. Standard 21 (21.1 – 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? A policy and procedure was in place for serious illness and death. Staff were able to demonstrate that the wishes of service users and their relatives would be respected in the event of serious illness and dying.The GrangePage 19 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: • • Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 – 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X 0 Standard met? 0Key findings/Evidence This standard was not assessed at this inspection.The GrangePage 20 Standard 23 (23.1 – 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence This standard was not assessed at this inspection. YESX Standard met? 0The GrangePage 21 EnvironmentThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 24 (24.1 – 24.13) The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 4 Key findings/Evidence Standard met? On touring the home it was observed to be suitable for its stated purpose. Décor and furniture and soft furnishings in the home were comfortable, well maintained and domestic in style. Service users and relatives spoken to were positive towards the high standard of communal and personal accommodation.The GrangePage 22 Standard 25 (25.1 – 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) – single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This standard was not assessed at this inspection. YES NO NO X X X X Standard met? 0 X XX X X XThe GrangePage 23 Standard 26 (26.1 – 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 4 Key findings/Evidence Standard met? Each bedroom viewed was individual in style and décor. The standard of furniture was high with appropriate specialist beds and equipment for service users with specialist needs. One service user who invited me to view his personal accommodation commented positively on the flexibility with reference to personalisation of his room as he had office area incorporating computer equipment, which he enjoyed using on a regular basis. The manager said all rooms are decorated prior to new service users moving in, if the prospective service user does not like the paint colour they can request that the colour be changed to one of their choice. A relative spoken to during the inspection said she was impressed with the high standard of personal accommodation. Standard 27 (27.1 – 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The home has an adequate number of washing, bathing and toilet facilities to meet the collective needs of the service users. It was observed that some rooms have additional ensuite facilities and a range of specialist bathing equipment was in place.Standard 28 (28.1 – 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 4 Key findings/Evidence Standard met? The home provides a range of communal seating and dining areas for service users comfort. The décor, furniture and furnishings are to a high standard and well maintained. There has been discussion with service users with reference to unitising the home, but the manager said service users prefer the home’s layout as it is. The company is still giving this recommendation made at previous inspections consideration.The GrangePage 24 Standard 29 ( 29.1 – 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The manager was able to demonstrate that the home has the appropriate specialist equipment and adaptations are in place to meet the collective and individual assessed needs of the service users.Standard 30 (30.1 – 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? On touring the home it was viewed to be commendable clean, bright and well ventilated with no offensive odours present. Since the last inspection the home has appointed a domestic assistant, as previously the care staff carried out this role.The GrangePage 25 StaffingThe intended outcomes for the following set of standards are: • • • • • • 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.Standard 31 (31.1 – 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and other’s roles and responsibilities. 3 Key findings/Evidence Standard met? Staff personnel files contained a copy of their job description. Staff spoken to were able to demonstrate their role and responsibility.Standard 32 (32.1 – 32.6) Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? A comprehensive training matrix was in place for the home. Each staff member had a training profile and evidence of up to date training attended was available for inspection. Staff spoken to during the inspection were positive towards self-development and said training is arranged on a regular basis appropriate to their role of responsibility.The GrangePage 26 Standard 33 (33.1 – 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX3 Key findings/Evidence Standard met? On the day of the inspection staff were employed in adequate numbers to meet the collective needs of the service users. Since the last inspection a range of ancillary staff have been appointed i.e. cook, domestic, activities co-ordinator and laundry assistant. This issue had been highlighted at the last inspection but has now been addressed and care staff can devote more time to service users. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Staff personnel files examined contained all the required information to show that a thorough recruitment procedure had been followed for the protection of service users. The manager said all new employees have a Criminal Records Bureau check before they commence in post.The GrangePage 27 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. 3 Key findings/Evidence Standard met? This standard is met (Refer to standard 32).Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Evidence was available to show that staff receives formal supervision a minimum of six sessions per year. A programme of supervision is in place. The manager delegate’s formal supervision of junior care staff to senior care staff, the manager countersigns the supervision report.The GrangePage 28 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 37 (37.1 – 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. YES3 Key findings/Evidence Standard met? Since the last inspection a new manager has been appointed. The manager has worked for the company for many years and is experienced in working with this client group. The manager has completed the Registered Managers Award and was able to demonstrate her role of responsibility.Standard 38 (38.1 – 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The manager described her management style as open, well organised and involving. The manager said she is developing her role with reference to managing a larger care home.The GrangePage 29 Standard 39 (39.1 – 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standards 40 (40.1 – 40.6) The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 41 (41.1 – 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This standard was not assessed at this inspection.The GrangePage 30 Standard 42 (42.1 – 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 43 (43.1 – 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? The area manger on the day of the inspection had available evidence of financial viability and a current Business Plan for the home.The GrangePage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Date Public reportsBelinda Parker Tanya Newton 4th April 2005Signature Signature SignatureRegulation Manager Michele HarganIt should be noted that all CSCI inspection reports are public documents.The GrangePage 32 PART DD.1PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 2nd March 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Provider’s response received at time of publication and available on file at Area Office.Action taken by the CSCI in response to provider comments: The Grange Page 33 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 1st April 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNONONOOther: enter details here The GrangePage 34 D.3PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, Mrs Anne Burrell, The Grange confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I, Mrs Anne Burrell, The Grange am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.The GrangePage 35 The Grange / 2nd March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000007510.V205394.R01© This report may only be used in its entirety. 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