Inspection on 21/11/06 for Tolson Grange

This inspection was carried out on 21st November 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Tolson Grange 21/10/08

Tolson Grange 30/10/07

Tolson Grange 23/01/06

Tolson Grange 03/10/05

Tolson Grange 11/02/05

Tolson Grange 08/07/04

Tolson Grange 09/03/04

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

CARE HOMES FOR OLDER PEOPLE Tolson Grange 12 Coach House Drive Dalton Huddersfield West Yorkshire HD5 8EG Lead Inspector Jacinta Lockwood Unannounced Inspection 21st November 2006 10:00 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 Tolson Grange DS0000026339.V320876.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. Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tolson Grange Address 12 Coach House Drive Dalton Huddersfield West Yorkshire HD5 8EG 01484 432626 01484 519126 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) susan.austin@anchor.org Anchor Trust Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: Tolson Grange is a residential home providing personal care and accommodation for up to thirty-eight older people with dementia. Anchor Trust, a national housing association and organisation providing residential care, own the home. Tolson Grange, is located on the outskirts of Dalton a residential suburb of Huddersfield. It is within walking distance of shops and public transport and there is car parking to the front of the property. Tolson Grange recently increased the number of rooms available by incorporating an attached former sheltered housing complex. The original home was purpose built for the current client group. The home has twentyfour large, single en-suite bedrooms and fourteen large single suites with bedroom, lounge and a walk-in shower room with toilet facilities. All rooms are fitted with privacy locks and an emergency call system. There are good communal facilities over three floors. Stairs and a shaft lift are available to allow access to the upper and lower floors. Security at the home is ensured through the provision of coded door locks. The home has enclosed sloping gardens. The Commission for Social Care Inspection was informed that as at 21.08.06 the fees ranged from £500.00 to £575.00 per week. Additional charges are made for hairdressing, chiropody, personal toiletries, magazines, etc. Information about the home in the form of a Statement of Purpose, Service User’s Guide and the latest Commission for Social Care Inspection report are available from the home. Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. TELL ENQ. MANAGER DETAILS NEED REMOVING BEFORE SENDING. As part of this inspection, one inspector carried out an unannounced visit to Tolson Grange on 21.11.06. The inspection started at 10am and ended at 7.15pm. For the purposes of this inspection the inspector spoke with six service users, six visiting relatives/friends, the home’s deputy manager and six members of staff. The inspector also spoke to two relatives by telephone. Observations were made on the day of the visit. Prior to this visit, questionnaires were sent out to obtain the views of service users, relatives, GPs and health and social care professionals. Surveys were sent to a sample of 10 service users at the home, 9 relatives, the surveyed residents’ GPs and 9 health and social care professionals. At the time of writing, 6 service user, 9 relatives, one GP and 2 health and social care professionals surveys had been received. The inspection findings are also based on a range of accumulated evidence received by CSCI since registration, for example, notifiable incident reports from the provider about deaths, illnesses, accidents and incidents at the home Information from other agencies and a pre-inspection questionnaire completed by the manager were also used. The records of three service users were inspected, including care plans, risk assessments, medication and accounting records held by the home. Other records sampled included the food menu, complaints log, staffing rota, staff recruitment and training records, health and safety records, maintenance records and some policies and procedures. A partial tour of the building was made, including the bedrooms of three service users whose care was casetracked as part of the inspection. A new manager has recently been appointed and is receiving induction training. The Commission expects that by the time of the next visit to the service action will have been taken to address those shortfalls identified during this inspection. The inspector would like to thank all those who contributed to the inspection process. Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Improvements are required to care planning and risk assessment documentation because sometimes paperwork is not completed or available and the information within care plans is not always specific or detailed enough to allow care and support to be delivered by staff in a consistent manner. Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 7 Staff with responsibility for administering medication must ensure that records are accurate so that there is a clear audit trail. Confidential information should be stored securely so that only those who have the right to do so can access the information. Although some activities are provided, work should continue to develop the range and frequency of these so that service users can be engaged in pastimes suited to their individual needs and capacities. The Chef Manager explained that steps are being taken to provide culturally appropriate food choices. This should be followed through so that individual service users have more choice. The home has recently been extended with a subsequent increase in the number of service users living there. Although staff recruitment is taking place to support the increasing number of service users, current arrangements mean that there is an increased number of service users using the ground floor lounge. This has the potential to cause problems owing to a lack of space and increased noise levels, something observed during the visit and also commented upon by a service user and a relative. The registered provider must ensure that sufficient skilled and competent staff are on duty to cater for the increased number of service users, taking into account the layout of the home. Staff training must continue so that all staff, particularly new employees, receive training relevant to the needs of the service user group. The way staff are deployed within the home also needs reviewing so that the skill mix of staff on duty is appropriate to the needs of people who have dementia and who may exhibit challenging behaviours. 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. Tolson Grange DS0000026339.V320876.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 Tolson Grange DS0000026339.V320876.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): 3 The needs of prospective service users are assessed before they are offered a place at the home and a contract/statement of conditions provided as confirmation that their needs can be met there. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 6 is not relevant, as Tolson Grange does not provide intermediate care. A community care assessment is obtained before a person is admitted to the home. The home also completes a pre-admission assessment. Prospective service users may visit the home before deciding to move there, although it is Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 10 usually a family member who visits the home on their behalf. It was evident from discussion with relatives and surveys received that pre-admission visits had taken place and information about the home was made available. One relative reported that during “An unannounced visit at Tolson Grange we were shown around and got a comprehensive view of the standards and facilities. The last CSCI inspection report was available for us to peruse.” A contract/statement of conditions is provided as confirmation of the placement. Service users who were able to comment and a relative indicated that they had received a contract. Copies were also held on service users’ files. Tolson Grange DS0000026339.V320876.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, 10 Generally, service users’ needs are set out in an individual plan of care. A range of professionals meets service users’ healthcare needs. Medication is generally dealt with appropriately. Service users are treated with respect and their right to privacy is upheld. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user has an individual plan of care based on their assessed needs. The plans are kept under review, although this was not always on a monthly basis as recommended in the National Minimum Standards for Older People. (See Recommendations.) The service user’s representative, usually the next of kin, is involved in formally reviewing the plan at six-monthly intervals. Relatives confirmed their involvement. There was evidence of attempts by staff Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 12 at the home to obtain the next of kin’s signed agreement with the care plan and service users’ relatives had signed some of the care plans seen. Risk assessments were available for a range of identified risks, including falls. Again, although these had been reviewed, they should be reviewed on a monthly basis, as recommended. (See Recommendations.) Since the last inspection, a new care plan format has been introduced and information is now more easily accessible. Care plans were based on the needs assessment and generally provided an improved level of information. However, to allow care to be provided in a consistent manner, information in care plans needs to be more specific. For example, entries such as ‘likes to go to bed late’, ‘check regularly’, ‘change regularly’ do not provide sufficient clarity to allow care to be provided in a consistent manner. This is particularly important where new employees or agency staff are on duty. (See Recommendations.) As discussed with the deputy manager during the visit, where it is evident that there is a potential for conflict between identified service users, this must be risk assessed and recorded within their plan of care so that it is clear to all involved what action needs to be taken to promote the service users’ health and safety. Also, as discussed with the deputy manager, all care planning documentation must be completed, as paperwork relating to the nutritional needs for one individual had been left blank. (See Requirements.) More attention should be paid to daily reporting, because entries did not clearly reflect the actual care provided each day nor whether the desired outcome for the service user was being met. (See Recommendations.) Survey information indicates that staff listen and act on what service users say. One survey indicated that “Staff always respond quickly”. Service users surveys indicated that they always receive the medical support they need. A range of healthcare professionals including GP’s, District Nurses, Optician, Chiropodist and Community Psychiatric Nurses, meet service users’ healthcare needs. A GP and three health and social care professionals indicated that staff at the home demonstrate a clear understanding of the care needs of service users and that, when they visit, they are able to see service users in private. They also indicated that any specialist advice is incorporated into the service user plan. Owing to the nature of their disability, none of the current service users self medicate. A relative stated that their relative “Receives a wide range of medication daily and this is always provided.” New staff are supervised when they administer medication and a training programme is in place. A sample of medication was audited. Medication records were generally well maintained, although where codes had been used, these were not always explained so it Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 13 was not clear why the code had been used. (See Recommendations.) The vast majority of the medications audited could be reconciled with records held. A requirement is made within this report for accurate medication records to be maintained. (See Requirements.) A relative reported that her relative “Always looks well cared for.” On the day of this unannounced visit, service users looked well groomed and cared for and a service user spoken with said that she was able to choose her own clothing. Staff were seen to treat service users in a kind and caring manner, with respect, and to uphold their privacy when providing care and support. Privacy locks are in place and service users, where able, may have a key to their private accommodation. One service user said that she could have had a key to her bedroom but had decided not to. It was evident from survey information and from comments received from service users and relatives that they are happy with staff at the home. Comments were received such as the staff “Are lovely, “Staff are always very pleasant and helpful”, “I find the staff warm and friendly” and “The staff are always kind and make themselves available to meet all needs”. Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 14 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 Service users are helped to exercise choice and to maintain contact with family and friends. They have opportunities to access community based facilities. Work is ongoing to increase the range of activities provided to service users. Service users receive a wholesome appealing diet suited to their needs. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A new activities organiser is in post and she showed the inspector an activities plan she is currently developing, taking into account service users’ preferences and abilities. Documentation entitled “Lifestyle Matters” has been put in place to capture service users’ likes, dislikes and preferences across a wide range of areas such as clothing, music, food and routines. Service users’ key workers are in the process of gathering this information. As discussed during the visit, for the exercise to be productive, recording needs to be specific because entries such as ‘likes listening to music’ tells the reader nothing about the type Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 15 of music the service user enjoys and provides little useful information to assist in the development of a meaningful lifestyle for service users. Activities had been rostered in for 10am to 4pm on the day of this visit. But, because the activities organiser was involved in staff recruitment, activities during the visit were limited. However, service users were engaged in conversation by staff and some enjoyed a sing-a-long and listening to a service user play a mouth organ. Records show that activities such as Pat-a-Dog, reminiscence, coffee mornings, cake decoration and chats with staff take place. However, the range and frequency of activities should be improved so that service users are engaged in a wider range of meaningful pastimes. One service user’s activity record indicated that the service user had a period of nine days without activities, even though the care plan noted a need for stimulation. The activities organiser is aware of the need for activities suited to individuals and the development of the Lifestyle Matters documentation would support her work in this area. (See Recommendations.) Service users maintain contact with family and friends. Visitors to the home said that they were made welcome and relatives reported that they can make visits in private. Shopping trips to a local supermarket were said to take place and in the near future, children from a local school are to put on a Christmas Carol concert for service users. Some service users enjoyed having their hair done during the visit by two hairdressers who visit the home on a regular basis. The promotion of choice was recorded within care plans. A service user said she choose what to wear and service users were offered choice with regard to food and drink and were able to move freely around the home spending time in the company of others or alone. Meals at the home are freshly prepared, wholesome and well presented. Home baked cakes and buns were provided with a choice of drinks at various times throughout the day. Special diets are catered for. The Chef Manager was aware of service users’ dietary needs and spoke of attempts to consult with a service user’s family about cultural dietary preferences so that a wider choice of foods could be made available. Where appropriate staff monitor service users’ food and drink intake, providing nutritional supplements where required following discussion with the service user’s GP. Monitoring records are also kept. Staff supported a service user, by showing the choice of main meal, so that the service user could choose. Service users commented positively on the food provided. A visitor was aware that a meal could be taken with their friend/relative if they wished. Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 16 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 Service users and their relatives and friends can be confident that their complaints will be listened to, taken seriously and acted upon. Generally, service users are protected from abuse. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure is on display and records are kept of any concerns, complaints and compliments received. There have been no recent complaints. Surveys indicate that people know how to raise a complaint should they have need to, but some service users would not be able to owing to their frailty. Relatives reported that “Both the senior carer and the manager are available to discuss issues” and “I have no concerns about Tolson Grange.” Appropriate action was taken when a recent adult protection issue was reported. However, the incident identified a need for staff to have further training around adult protection and their responsibilities. All staff have since signed a document to say that they have read and understood the home’s complaints, whistle-blowing and rights and responsibilities policy and procedure. Staff spoken with were aware of the action to take were they to Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 17 see or suspect abuse. Protection of Vulnerable Adults training has been provided to the majority of staff and further training has been arranged for early December 2006. However, until all staff currently employed have received this training a requirement is made. (See Requirements.) As discussed with the deputy manager at the time of this visit and as noted under the section on Health and Personal Care, where it is evident that there is conflict between identified service users, this must be risk assessed and recorded within their plan of care so that it is clear to all involved what action needs to be taken to promote the health and safety of individual service users. During the visit there was an incident between two identified service users to which staff responded quickly. This will be addressed under the section on Staffing. Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 18 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, 26 Service users live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Tolson Grange has recently extended its facilities and the home has been completely redecorated to a high standard. Professional advice was sought regarding the colour scheme, taking into account the needs of the service user group. Some new furniture has been purchased together with pictures and ornaments giving the building a homely and welcoming feel. Positive Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 19 comments were received about the home’s environment such as it’s a “lovely environment” and it’s “homely”. Service users’ expressed satisfaction with their private accommodation, which reflected their personal tastes and interests and said they were able to bring some items of furniture with them to personalise their room. Equipment is provided at the home to meet service users’ diverse needs. There are four day/quiet rooms that service users can use. Because the newly refurbished extension has some vacant bedrooms, service users based there are encouraged to use the lounge and dining facilities on the ground floor so that staff can provide support and supervision. This is not ideal, as there is increased pressure on these facilities. One service user said of the lounge that “There’s too many people here”. A relative also commented that the area was not big enough for the number of people using it. (See Recommendations.) The deputy manager acknowledged the situation and explained that new staff were being recruited to cover the new unit so that communal facilities in that part of the building could then be used. Although one relative reported that “The standard of cleanliness is not up to the standard it used to be”, another reported that “Standards of cleanliness are very high and the home is always fresh and aired”. Domestic and laundry staff are employed to ensure standards of hygiene are maintained. On the day of the visit the home was clean, tidy and odour free. Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 20 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 Generally, service users needs are met by the numbers and skill mix of staff. NVQ (National Vocational Qualification) training is ongoing to ensure that service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Not all current staff have received full training to ensure they are trained and competent to do their jobs. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Half of those relatives returning surveys felt that staffing levels were not always sufficient. Mixed views were received from long-standing and relatively new staff about this. Current daytime staffing levels are usually 2 senior and six care staff on the morning shift and one senior and five or six carers on the afternoon shift. From records, discussion and comments received, it appears that there are occasions when daytime staffing levels are not always sufficient to meet the needs of current service users taking into account the recent increase in the number of service users. (See Requirements.) Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 21 A recent adult protection issue highlighted the need for the skill-mix of staff on duty to be considered. From observation and discussion, although a longstanding and experienced member of staff was working with two relatively new staff members, the new staff members had not yet received dementia and challenging behaviour training. As noted under the section on Complaints and Protection, two service users were involved in an altercation, which staff responded to quickly but which could have been managed differently so that the service users were not able to continue the altercation. It’s important for staff to receive appropriate training so that they have the skills and knowledge to deal with such incidents and so that they and service users are not placed at unnecessary risk. Also, as noted under the section on Health and Personal Care above, where it’s evident that there is a potential for conflict between identified service users, this must be risk assessed and recorded within their plan of care so that it’s clear to all involved what action needs to be taken to promote the service users’ health and safety. (See Requirements.) Standard 28 refers to NVQ (National Vocational Qualification) training. Thirtyseven percent of staff hold an NVQ Level 2 or equivalent qualification and NVQ training for staff is ongoing. The National Minimum Standards for Older People recommend that a minimum 50 of staff should hold an NVQ Level 2 qualification or equivalent so that service users are in safe hands. (See Recommendations.) The staff group is culturally diverse. Staff confirmed the recruitment process in discussion with them. Recruitment records for two staff members were checked and contained the required information. On the day of the visit interviews were taking place to recruit to vacant posts that are currently being covered by existing and agency staff. It was evident from records and discussion with staff that a range of suitable training, including induction training, is provided and that further training has been planned. And it’s positive to note that new staff are supervised when they begin working at the home. However, as noted elsewhere in this report, not all staff on duty have received all the training relevant to this client group. The deputy manager explained that a lot of training had been arranged but because the trainer left employment the training had not taken place. Arrangements must be made to ensure that staff who have not yet done so receive training appropriate to their work, particularly dementia care and challenging behaviour training. (See Requirements.) Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 22 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 A new manager has recently been appointed to run and manage the home. Quality monitoring systems are in place to ensure that the home is run in the best interests of service users. Service users’ financial interests are safeguarded. Health and safety is promoted within the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 23 A new manager has been appointed and is undergoing induction training. The deputy manager has been managing the home with support since the previous manager left. Standard 31 could not be fully assessed, therefore, as it refers to the home’s registered manager. However, the deputy manager is a longstanding, experienced member of the team who has a good knowledge of the service user group. A quality monitoring system is in place. A survey report from June 2006 was available and indicated satisfaction with the services provided at the home. The survey report was displayed in the entrance area and available to those wishing to read it. All the surveys received from relatives and those spoken with expressed satisfaction with the overall care provided at the home as did those professionals returning surveys. Monthly management visits also take place. A recent report identified a need for some areas of training, for example, NVQ and protection of vulnerable adults, to be updated. Although management visit reports required under Regulation 26 of The Care Homes Regulations 2001 are not now routinely requested by the Commission, the inspector feels it would be appropriate given some of the findings of this report, for the reports to be forwarded to the Commission on a monthly basis so that any improvements at the home can be monitored. (See Requirements.) The deputy manager explained the system in place for handling service users’ monies. Accounting records for service users’ monies were seen and these were clear and up-to-date. Some service users’ care records were being kept in one of the communal areas, but the storage was not secure. This should be addressed so that only those who have a right to do so can access the information held there. (See Recommendations.) Accidents and incidents are recorded. Where service users are at risk of falling, risk assessments are put into place and as part of the monitoring system, a register of falls is completed. Accidents and incidents are also notified to the Commission as required. First aid supplies were available and, so far, eight staff have received training in first aid. A health and safety policy statement was available for inspection. A sample of maintenance documentation was checked and shows that equipment is serviced as required. Monthly health and safety checks are also carried out, but the record of fire alarm and emergency lighting tests could not be located at the time of the visit. This must be available to staff and for inspection. (See Requirements.) Discussion with staff and records show that staff fire safety training is ongoing so that staff know what action to take in the event of a fire. Fire safety Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 24 equipment is also serviced as required. The home’s fire evacuation procedure was clearly displayed throughout the home. Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 25 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 26 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 All of the service user’s identified needs must have a corresponding plan of care which details how those needs are to be met. (Timescales of 03.12.05 and 31.03.06 not met). Care planning documentation; including nutritional risk assessments, on service users’ file must be completed. Where it is evident that there is a potential for conflict between identified service users, this must be risk assessed and recorded within their individual plan of care. Accurate medication records must be maintained. Timescale for action 22/12/06 2. OP7 15(1) 13(4)(c) 22/12/06 3. 4. 5. OP9 OP18 OP27 17(1)(a) Schedule 3 (3)(i) 13(6) 18(1) 22/12/06 6. OP30 18(1)(c) (i) All staff currently employed must 22/12/06 receive training in adult protection. Sufficient numbers of qualified, 15/12/06 competent and experienced care staff must be available to meet the needs of service users. Staff working at the home must 22/12/06 receive training appropriate to DS0000026339.V320876.R01.S.doc Version 5.2 Page 27 Tolson Grange 7. 8. OP33 OP38 26 23(4)(c) (v) their work, therefore, staff who have not done so must receive training in dementia care and challenging behaviour. Monthly reports required under Regulation 26 must be supplied to the Commission. The home’s record of fire alarm and emergency lighting tests must be available to staff and for inspection. 22/12/06 22/12/06 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 OP7 Good Practice Recommendations Care planning documentation, including risk assessments, should be reviewed on a monthly basis. Care planning information needs: to be more specific rather than entries such as ‘check regularly’, so that clear instructions are available to staff as to how they are to meet service users’ health and welfare needs consistently. to be signed and dated so that the currency of the information is clear; to include risk assessment findings; to be completed accurately Daily reports on service users should clearly reflect delivery of the care plan and the outcomes to that care. Where codes are used on the Medicines Administration Record (MAR) sheet, these should be explained. The range and frequency of activities available to service users at the home should be increased and reflect their personal preferences, needs and capacities. The home’s Lifestyle Matters documentation should be completed in such a way that the information recorded there is detailed and meaningful. A choice of culturally appropriate foods should be available to service users, therefore, work should continue to obtain DS0000026339.V320876.R01.S.doc Version 5.2 Page 28 3. 4. 5. 6. 7. OP7 OP9 OP12 OP12 OP15 Tolson Grange 8. OP20 9. OP27 10. OP28 11. OP37 information about service users’ individual preferences. Better use should be made of communal space, particularly lounge areas, so that service users do not have to congregate in the ground floor lounge because staff are available there to provide support and supervision. Staff deployment at the home should take into account the skills and knowledge of the care staff on duty on any one shift so that the skill-mix of staff is appropriate to the number and needs of service users. The registered person should ensure that a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) is achieved. (Recommendation carried forward). Individual service user records should be stored securely. Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Tolson Grange DS0000026339.V320876.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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