Inspection on 08/12/06 for The Grange Centre

This inspection was carried out on 8th December 2006.

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

The inspector found 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 Centre 25/10/05

The Grange Centre 23/08/05

The Grange Centre 18/11/04

The Grange Centre 11/05/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Sutton Lodge Nursing Home

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Grange Centre (The) Rectory Lane Bookham Surrey KT23 4DZ Lead Inspector Helen Dickens Key Unannounced Inspection 8th December 2006 10:00 Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grange Centre (The) Address Rectory Lane Bookham Surrey KT23 4DZ 01372 455225 01372 451959 ellie.smith@grangecentre.org.uk 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) The Grange Centre Eleanor Ruth Smith Care Home 20 Category(ies) of Learning disability (20), Learning disability over registration, with number 65 years of age (4), Physical disability (20), of places Physical disability over 65 years of age (4), Sensory impairment (20), Sensory Impairment over 65 years of age (4) Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Condition One The Home may be accommodate up to 4 residents within the categories LD(E), PD(E) and SI(E) Condition Two The age/age range of the persons to be accommodated will be: 20 65 YEARS, with up to 4 OVER 65 years 25th October 2005 Date of last inspection Brief Description of the Service: The Grange Centre is situated in its own extensive grounds on the outskirts of Bookham in Surrey. The service is registered to provide residential care for up to 20 residents in the above categories. Gloucester Lodge is a single storey purpose built unit with three wings, each having a kitchen and lounge/dining room – each wing provides accommodation for 5 residents. The final phase of the building programme is now complete and provides a fourth wing with self contained accommodation for a further 5 residents. There are on-site educational and recreational facilities for residents including a horticultural centre and a creative textile workshop. There is also a shop which sells some of the produce from these activities. There is parking near Gloucester Lodge itself and elsewhere on site. The cost per person per week is £703. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours and was the first key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to June 2007. The inspection was carried out by Helen Dickens, Lead Inspector for the service. The Registered Manager, Eleanor Smith, and the Chief Executive Officer (CEO) of The Grange Centre, Judith Walker, represented the establishment. A partial tour of the premises took place. The inspector interviewed 3 residents and spoke with several others during the day. In addition to the Registered Manager and CEO, two members of staff were also spoken to. A number of documents and records were examined including resident’s files, staff recruitment files and a number of health and safety certificates were sampled. This was another busy day at The Grange Centre and the Inspector would like to thank the residents, staff, the Registered Manager, and the Chief Executive for their time, assistance and hospitality throughout. What the service does well: The Grange Centre provides a homely and pleasant environment, with good quality furnishings and fittings and the premises are clean and hygienic throughout. The resident’s satisfaction questionnaire carried out by the home in 2005 shows the greatest level of satisfaction is with the home’s environment. Resident’s independence is well supported, and the on-site facilities for resident’s training and leisure activities are excellent. The life skills and literacy department aims to equip residents with independent living skills. The horticultural centre and creative textile workshop facilities are open to residents, tenants who live in the supported housing on other parts of the site, and to non-residents for day care: this gives a greater social circle and more opportunities for friendships to develop. Staff were observed to treat residents with consideration at all times and there was much evidence of resident’s autonomy, privacy and dignity being respected. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care plans for retired residents should be reviewed monthly as set down in the National Minimum Standards for older people. In addition to the specialist training and advice on their medication policy from a pharmacist, the home should also seek professional advice on the overall arrangements for the administration of medication. To avoid confusion, the home’s policy on protecting vulnerable adults should be up-dated to include the terminology used in the Surrey multi-agency procedures for the protection of vulnerable adults. The information set down in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001 (as amended) must be sought for all new staff particularly those who began working at the home since July 2004 when the latest amendments came into force, and staffing numbers must be reviewed in the light of the changing needs of individual residents. The information gathered as part of the quality assurance processes at the home should be used to determine the annual development plan for this home. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 and 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective resident’s individual aspirations and needs are assessed and they have the opportunity to test drive the home. Each resident has an individual written contract with the home. EVIDENCE: Pre-admission assessments were well done at this home and all aspects of resident’s needs and wishes are explored. Prospective residents can come for a day or part of a day to ‘test drive’ the home as well as try the training and work placements at The Grange Centre. Some residents stay for longer as part of their assessment and stay in the ‘assessment’ room. This gives the prospective resident a better opportunity to try out the facilities, and mix with other residents. Three resident’s assessments were sampled and in addition to care manager’s assessments, there were also specialist assessments from resident’s previous college placements, as well as speech and language reports. One resident had stayed for a two week pre-admission assessment and that was also well documented. Two residents spoken to had had their stay extended in the assessment room in order to provide continuity until the final phase of building of the new wing is complete. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 10 A recommendation at the previous assessment to include a room number or other identifying factor regarding which room each resident was entitled to occupy as their personal bedroom, has since been completed and the three files sampled now contained this information. The statement of purpose is currently being up-dated to take account of the completion of the final phase of the home’s building programme. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s can be confident that their assessed and changing needs, and their personal goals, are reflected in their individual plans. Resident’s make decisions about their lives with assistance as needed, and are supported to take risks as part of an independent lifestyle. Residents participate in all aspects of life in the home. EVIDENCE: Three care plans were sampled and found to be well done. They contained a detailed record of each resident’s abilities, disabilities and health needs, personal care needs and family and social relationships. Risk assessments were appropriate and reviewed in a timely fashion. Resident’s reviews were thorough and showed the input from the resident and their family. Particular attention was paid to communication needs, healthy eating, exercise, and the Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 12 self-administration of medication. The home has a structured programme of training and work available for residents and each plan sets out the goals and aspirations for each resident with regard to these activities, as well as for other social and leisure pursuits. The registered manager was reminded that the ‘retired’ residents should have their care plans reviewed on a monthly basis to comply with the National Minimum Standards for older people. Resident’s spoken to had been given many opportunities to make decisions and take risks in their day to day lives. For example, residents were encouraged to administer their own medication and a special system had been devised to enable residents who wish to, to do this with the appropriate support. Other evidence of this freedom to make decisions and take risks can be seen throughout the home as some residents have chosen to smoke, some to engage in personal relationships, and others to share their bedroom. Residents attend resident’s meetings and notes are kept on the outcome of any matters raised. Some represent the interests of the group at management level, and another is the resident representative at the health and safety committee meeting. One resident who had been involved in this way was knowledgeable on the relevant issues to bring to the meeting and felt that issues raised in the past had been appropriately addressed. Outcomes of service user satisfaction questionnaires are published within the home and from next year will be in The Grange Centre’s regular newsletter. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities for personal development and are able to take part in appropriate activities. Residents are part of The Grange Centre community, as well as the wider local community. Residents engage in appropriate leisure activities and in personal and family relationships. Their rights and responsibilities are recognised, and they are offered a healthy diet. EVIDENCE: The life skills department at this home offers opportunities for residents to improve their daily living skills in a number of ways including social skills, managing money and travelling and getting about. The ‘literacy’ department encourages residents to learn or improve their reading, writing and creative writing abilities and therefore continue with their education once they come to live at this home. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 14 The work experience department aims to find suitable voluntary and paid work placements for tenants in the sheltered housing and for some residents at the care home. Most residents, except those who are retired, choose to work either in the onsite creative textiles centre, or on one the horticultural projects. An on-site shop sells produce from the horticultural centre and items from the creative textile workshop. In addition to the above, residents engaged in a diverse range of social and leisure opportunities, including on-site activities, such as aqua-aerobics in their own swimming pool. When checking staff training certificates, some staff had the ‘rescue test’ certificate with the Royal Life Saving Association – the manager said staff who want to access the pool with clients must have this training course which is specifically for supervising swimmers with disabilities. Some residents were going out that evening to see the recently released ‘Happy Feet’ at the local cinema. Retired residents had their own interests and activities which they pursued. Bird feeding was popular and at a previous inspection one resident noted that there were 16 different bird species visiting the numerous bird feeders which she kept topped up outside her window. One resident visited during this current inspection hosted ‘Cheetah’ the house cat who had made himself fully at home on her bed. Outside activities included belonging to various church, community and ‘hobby’ groups. All residents helped with housekeeping tasks and a resident showed the inspector the rota where everyone took turns to set the table, empty the dishwasher etc. Resident’s were encouraged to keep family and friendship contacts and the registered manager was knowledgeable about resident’s families. Staff enable residents to access information and advice on issues relevant to personal relationships. Staff were observed to be respectful to residents at all times and resident’s rights were respected, for example some residents have chosen to smoke. The new wing at this home gives residents their own front door to their studio apartment, giving them more responsibility and independence. There were no examples of staff speaking exclusively to each other, indeed whilst the inspector was on the tour of the home the registered manager and chief executive were observed to try hard to include residents wherever possible, allowing them to express their opinions and make a contribution to the process. Residents at this home enjoyed their meals and dining/lounge areas were comfortable and offered a pleasant place to eat. On the day of the inspection one unit had noodles on the menu but a resident who did not like noodles was asked what she would like as an alternative, and in the end several residents Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 15 had chosen something different. There were fresh vegetables and salad in the kitchenettes and fresh fruit in the lounges for residents to help themselves. The manager said residents had input into menus and notes from resident’s meetings documented requests and comments from residents on this subject. As mentioned earlier, residents help with household chores including in their kitchen, which gives them more involvement in the arrangements for meals. Healthy eating is one of the subjects taught to students in the life skills department. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and require and their health needs are met. Medication is organised in a way which gives autonomy to residents, and the related policies and procedures protect their interests. EVIDENCE: From discussions with the service users and staff, and set down in resident’s care plans, the home works hard to ensure that resident’s personal care needs are met. No negative issues regarding personal care were raised by residents and those residents spoken to had only praise for staff and the support offered. Training records showed that staff had received appropriate training for example moving and handling to enable them to assist residents safely. The care plans also outlined resident’s healthcare needs and actions taken to ensure these were met. Service users are all registered with a local GP and referrals to other health care professionals are obtained as necessary. A variety of specialist health interventions and reports were seen on residents Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 17 files. The home has good relationships with community health professionals and at the start of the unannounced inspection a meeting with someone from the Community Learning Disabilities team was in progress. The home uses the Medisure system for almost all resident’s medication and these are supplied by the local pharmacy. Special arrangements for one resident were discussed in more detail and found to be satisfactory. Medication arrives with a whole week’s medication in each cardboard folder – residents take these out themselves. Staff order medication and collect prescriptions. Residents keep up to a week’s supply in their rooms, though others who have been assessed as needing more assistance are given it on the day the medication is due. Medication records are only signed by staff when stocks are received and for ‘as required’ medications. A pharmacist adviser from the local pharmacy company set up the original system and the home now uses a specialist medication training consultant to check the medication policy and deliver training to staff. The local pharmacy supplies a ‘doom kit’ for the disposal of unwanted medicines which is then collected by a medication disposal company. The registered manager was reminded that advice on all aspects of medication administration should be sought from a pharmacist and they should consult the local health trust to ascertain what arrangements have been made in their area. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s concerns are taken seriously and they are protected from abuse. EVIDENCE: One complaint has been received in the last year from a relative regarding smoking in the home. The home has since revised the smoking policy and now there is no smoking indoors. A smoking shelter is available outside and more weather proofing is being added. The manager said the complainant, residents and staff were happy with this arrangement. The home has a complaints procedure and residents spoken to knew how to raise a concern. The new Chief Executive was very visible within the home and residents appeared to know her well; she and the new manager were observed to be approachable to staff and residents many of whom came over to chat to them during the inspection tour. The home’s procedure for the protection of vulnerable adults works well and one issue which has been raised since the last inspection has been dealt with appropriately by the home and referred to social services in a timely fashion. The latest copy of Surrey’s local multi-agency procedures was available in the home and accessible to staff. The home’s own procedure needs up-dating to dovetail with the Surrey procedures (e.g. some of the terminology was different and this may cause confusion). Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 19 Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment and the home is clean and hygienic throughout. EVIDENCE: Gloucester Lodge at The Grange Centre is purpose built with three separate units offering accommodation for 15 residents plus an assessment room for those considering a permanent move to the home. The final phase of their rebuilding programme was nearing completion at this inspection and will offer a further five self contained flatlets for residents as well as a sleep-in room for staff. This year’s results from the annual resident’s questionnaire were still being collated but last years results showed that residents rated the quality of the environment very highly. When asked to comment on their satisfaction with the furniture and decoration, cleanliness, maintenance and repairs, and access, residents gave these the highest number of ‘very satisfied’ scores. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 21 The furnishings and decoration are domestic in character. The premises are safe, bright, cheerful, and airy with sufficient light, heat and ventilation. Gloucester Lodge and the ground floor of the new Victoria Lodge are accessible to wheelchairs and there are four wheelchair users currently living in Gloucester Lodge. Very detailed arrangements have been made in relation to fire safety on this site as, in addition to the registered care home, there are a number of educational areas including workshops, and a number of residents who live more independently in supported living. The home are diligent in ensuring all visitors have signed in and that proper procedures are followed in the event of a suspected fire. One unit had had a panel removed from under the kitchen sink to allow access for wheelchair users who were using the kitchen sink. Since the last inspection a more decorative arrangement has been made – one resident chose the material and a curtain has been made to fit across the space to hide the pipe work etc which was visible and out of keeping with the otherwise homely and well kept appearance of this home. The home is clean, pleasant and free from offensive odours. To maintain a good standard of hygiene all communal hand washing facilities have individually dispensed soap and paper towels and there are suitable arrangements in place for dealing with laundry and the control of infection. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and qualified staff though staff numbers need to be reviewed in the light of the changing needs of some residents. Recruitment practices need further work though arrangements for training are excellent. EVIDENCE: Staff were observed to be approachable and comfortable with residents and training records show that the necessary training is provided to ensure staff are competent to perform the work they are being asked to do. There is an emphasis on independent living and the care staff and educational staff who operate the student placements on site are all working with residents towards their individual goals and aspirations. 50 of care staff currently have NVQ 2 or above and others are enrolled on NVQ courses. The home has an effective staff team and residents interviewed had only praise for staff and the assistance that was available in the home. Specialist services are used both within The Grange Centre and externally from health and community services. The staff rota was displayed in the office and those Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 23 staff on duty were observed to be sufficient to assist residents and to communicate well with them. The specific needs of one resident were discussed and the registered manager and chief executive officer were asked to review staffing levels, particularly at night, in the light of this resident’s changing needs. A recommendation will also be made to use the Residential Forum matrix calculation when setting the overall staff to resident ratio, as set down in this Standard (33.3). This home has a system in place for the selection and recruitment of staff and this includes input from residents who live at this home. At the last inspection a resident was observed to be showing a prospective new staff member around the home. Staff files examined showed new staff had had criminal record bureau checks carried out and had been checked against the list of those deemed unsuitable to work with vulnerable adults. However, more work needs to be done to ensure information set down in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001 (as amended) is sought for all new staff. In particular, a full employment history should have been taken up for all staff who began employment at the home since July 2004 in order that any unexplained gaps can be followed up. In addition, the registered manager was reminded that a reference must be sought from an applicants last care employer, even if that employment ceased some years ago. All appointments are subject to a probationary period, and volunteers undergo the same vetting procedures as paid staff. Training and development arrangements at this home are excellent. There is a policy on training and development, a training plan, and individual training folders are kept for all staff – three of these were sampled and found to be well kept with a system in place for flagging up mandatory training which needed up-dating. The new common induction standards have been introduced and staff have LDAF accreditied training. Specialist training is commissioned as required for example the medication training from a pharmacist consultant, and the ‘rescue test’ for supervising disabled swimmers. The Assistant Director co-ordinates the training arrangements including a designated budget. Staff are expected to complete course evaluation sheets for all training courses and these are used to inform future training arrangements. The Management Board has a sub-committee which overseas personnel matters on behalf of the Board. The registered manager also gave examples of how residents were able to have input into staff training requirements. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home and quality assurance processes are good. The health, safety and welfare of residents are promoted and protected. EVIDENCE: The manager has registered with CSCI during the last year and has had 20 years experience in care settings. She has worked in this home since 2001 initially as a senior support worker. She progressed to the deputy post in 2004. She has started the Registered Managers Award and NVQ4 in Health and Social Care. She keeps her own professional training up-to-date and in the last 12 months has attended courses on fire safety, moving and handling, medication administration and a medication assessor’s workshop with the pharmacist consultant. The manager ensures policies and procedures are followed, correct Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 25 certificates and licences are obtained and displayed, and the home complies with CSCI Regulations and Standards. This home has a number of good quality assurance processes in place. There is annual questionnaire for residents which covers a range of issues of relevance such as staff, environment, and social opportunities. Some residents need support to complete this and results are reported back to the manager. A volunteer then assists a client to put this onto the computer and converts the results into statistics. Actions are taken e.g. regarding themes to do with particular areas such as food. The coloured chart is posted in the home for people to see, including on the office wall. The manager said the results of the 2006 survey are currently being collated and copies of the final results will go in the care office and client’s kitchen units, and would go in the quarterly newsletter in 2007. Currently there is no annual development plan though the home has all the components necessary. The chief executive officer checked the general business plan for reference to The Grange Centre care home, but it was felt that there was insufficient detail regarding the aims and outcomes for residents so a separate document will be put together. Other involvement by residents includes their representation on various committees such as the health and safety committee. The resident who represented the home on this committee outlined to the inspector what was involved and confirmed that issues highlighted are properly dealt with. Two residents form the home represent all residents at the consultative forum which addresses the council of management for The Grange Centre. They also have Regulation 26 monthly visits and try to interview two different residents on each visit. There are also annual care manager’s reviews and residents complete their own form with their views, sometimes with staff support. There are monthly resident’s meetings which are minuted and there is the complaints book. The arrangements for health and safety matters at this home are good and in a number of areas they do particularly well. The arrangements for fire safety are good, with all staff carrying a ‘fire pager’ which alerts them to the fire alarm being activated in one of the buildings on site. Some staff live on-site and it is a condition of their tenancy that when they are at home, even if they are not on duty, they will respond to fire alerts. The alarm was activated in one block during a previous inspection and provided a demonstration of how well the system works. Residents followed the evacuation policy and staff on site were on hand immediately. During the tour of the premises it was noted that the hazardous substances cupboard was secure, and the CSCI registration certificate and the home’s insurance certificate, current to March 2007, were displayed. There were no Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 26 obvious hazards and risk assessments were in place regarding potentially hazardous activities such as the administration of medication, the presence of liquids such as bubble bath etc in resident’s rooms, moving and handling, and use of the swimming pool. At the last inspection the home had reviewed its procedures for protecting against legionella and the staff member responsible for health and safety was particularly knowledgeable on this subject. Since then the home has used a specialist consultant to review all water safety issues and the remedial actions highlighted are being dealt with. The chief executive officer is ensuring that the actions identified are met in a timely fashion. As well as a full time health and safety officer employed on site, The Grange Centre also employs a consultant to advise them on health and safety matters. During the inspection a partial tour of the newly refurbished wing took place. The facilities and space for residents will enable them to have more independence and privacy as the wing has completely separate flatlets each with its own front door. A discussion followed with the Chief Executive and a number of health and safety documents were requested once they become available, to demonstrate that the new wing fully complies with current regulations. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 4 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 28 No 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 YA33 Regulation 18(1)(a) Requirement The registered person must review staffing levels, particularly at night, in the light of individual resident’s changing needs, as discussed during the inspection. The registered person must ensure information set down in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001 (as amended) is sought for all new staff as discussed during the inspection. Timescale for action 10/12/06 2. YA34 19 Schedule 2 15/12/06 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 OP7 YA20 Good Practice Recommendations The registered person should ensure that older people’s care plans are reviewed monthly as per this Standard. In addition to the specialist training and advice on their medication policy already commissioned, the registered person should also seek professional advice on the overall arrangements for the administration of medication. DS0000013657.V323029.R01.S.doc Version 5.2 Page 29 Grange Centre (The) 3. YA23 4. 5. YA33 YA39 The registered person should ensure the home’s own written procedure is up-dated to dovetail with the Surrey multi-agency procedures for the protection of vulnerable adults (e.g. some of the terminology was different and this may cause confusion). The registered person should use the Residential Forum Matrix, recommended by the Department of Health, to calculate resident:staff ratios. An annual development plan should be compiled to pull together the existing quality assurance and forward planning processes. Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Grange Centre (The) DS0000013657.V323029.R01.S.doc Version 5.2 Page 31 - 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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