Inspection on 25/05/06 for Upton Grange

This inspection was carried out on 25th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Upton Grange 17/05/07

Upton Grange 18/08/05

Upton Grange 18/04/05

Upton Grange 10/11/04

Upton Grange 19/07/04

Upton Grange 18/02/04

Upton Grange 05/11/03

Upton Grange 07/01/03

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

CARE HOMES FOR OLDER PEOPLE Upton Grange 214 Prestbury Road Macclesfield Cheshire SK10 4AA Lead Inspector Judith Morton Key Unannounced Inspection 25th May 2006 09:30 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 Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 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. Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Upton Grange Address 214 Prestbury Road Macclesfield Cheshire SK10 4AA 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) 01625 829735 01625 820266 Cheshire Residential Homes Trust Ms Jacqueline Ross Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2005 Brief Description of the Service: Upton Grange is one of three care homes owned by the Cheshire Residential Homes Trust, which is a charitable non-profit making organisation. It provides residential care for older people who have personal care needs only. There is one bedroom available for a person to stay for short-term respite. A committee manages the care home.The home is close to Macclesfield town centre. There are a number of shops, and other facilities located nearby. There are adequate car parking facilities available at the home.Upton Grange is a two-storey building and service users are accommodated on both floors. Access between floors is via a shaft lift or the stairs. Service users accommodation currently consists of 25 single bedrooms of varying sizes, all of which have en-suite facilities. Communal space consists of 2 lounges and a dining room. There is a large private garden with walkways and seating areas available for service users. There is also an enclosed courtyard seating area. In the pre-inspection questionnaire received by the Commission for Social Care Inspection, (CSCI) on 01st May 2006 the manager has written that the weekly charge to residents living at Upton Grange is £422.00 per week. Additional charges are made for hairdressing, toiletries, chiropody, dentist, opticians and newspapers. Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit, part of the key inspection for this service, took place over 11 hours, spread over two days, on 25/05/06 and 31/05/06. This included feedback to the manager on the second day. The committee chairperson was invited to attend for feedback but was unable to. The second day started at 7:20am so that discussion could take place with the night staff before they went off duty. Five residents care files were checked, two staff files, staffing rota, health and safety checks, activities timetable, menu and supervision records. Discussion with 6 residents, 11 staff, including the chef manager, chef and 2 housekeeping staff, 3 visitors and a locum GP, took place over the two days. A tour of the home was also made. The manager had provided the inspector with a pre-inspection questionnaire and a questionnaire was returned from a Social Care worker from Social Services. What the service does well: What has improved since the last inspection? What they could do better: Staff training needs to be monitored more closely to ensure that refresher training is provided to staff as it becomes due. A staff training matrix might help with this. Regular staff meetings should be held so that staff can be kept up to date with any changes to work practice, policy and procedures. Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 6 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. Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 7 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 Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the service. The pre-admission assessment contained sufficient information for the manager to know whether Upton Grange would be able to meet the persons’ specific needs. EVIDENCE: There was a pre admission assessment on each of the five residents files checked. This contained sufficient information for the manager to know whether Upton Grange would be able to meet the persons’ specific needs. The assessments had not been signed by either the staff member completing it or the resident or their representative. It was unclear because of this, who had completed it and whether the resident or representative had been involved in the assessment process. (See requirement 1) On one assessment it stated that the resident had an allergy to tomatoes. It was suggested to the manager that some information is needed as to how the resident would be affected if she accidentally ate tomatoes or tomato based Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 9 meals. This would enable staff to identify what the problem was and how they should respond. The manager asked the resident this and said she would update the assessment and care plan. More detailed information should be gained during assessment if it is felt that the resident’s health and safety could be at risk. (See recommendation 1) Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the service. The detailed profile gives staff a good insight into the resident but more detail in the care plan would ensure that all of the residents needs were being addressed and met. EVIDENCE: Five residents care files were checked. There was a good profile of the resident on three of the files, some containing more detail than others. This document and the full care plan had not been signed by either the resident or their representative so there was no way of knowing where this information had been obtained and whether the resident agreed with the content of their plan. The resident or their representative must be involved in devising their care plan and sign all documents. (See requirement 1) The care file of the newer resident was partially completed on the first day of inspection and had been completed by the second. However, this resident had lived at Upton Grange since 19/03/06. A care plan must be drawn up Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 11 immediately so that staff are aware of their role in meeting the residents identified needs. (See requirement 2) Another resident’s file described that the resident had suffered a stroke. More detail of how the resident is affected by this ie, which side is effected would give staff useful information about which direction to approach from, which side to place objects, drinks etc. It says in the resident’s file that the resident can no longer read or concentrate on puzzles but is a well-educated person. Staff should be find creative ways of helping her to continue to understand written documents such as her care plan, residents questionnaire etc. (See recommendation 2) It was identified in the assessment that the resident likes to have two baths a week but there is no mention of this in the care plan. The daily records on one file said “ he has done his exercises”. There was nothing recorded to say that the resident had to do these, what they were and how frequently. The manager said that the physiotherapist visits and leaves the resident some exercises to do. This should be written into the care plan so that, even if the gentleman doesn’t need assistance to do them, staff can check that they are being done at the frequency required by the physiotherapist. Care plans must be detailed to cover every aspect of the residents’ daily needs, including any specific instructions from health care professionals. (See requirement 3) Various risk assessments were available on all of the files although on one file it was stated that the resident had a problem with balance occasionally. There was no risk assessment to cover this and the resident had had a fall in Upton Grange, which resulted in a serious injury. Another file said that the gentleman was admitted following recovery from a serious injury at home due to a fall. There had not been a risk assessment carried out at Upton Grange to cover this. Risk assessments must be provided to cover every aspect of the residents’ assessment where there is potential risk identified. (See requirement 4) Some of the files contained photographs of the resident while others did not. The manager said she was currently working on this. It is good practice for all files to display a photograph of the resident. (See recommendation 3) The daily records were being completed in more detail; however, they were still being completed without the residents’ involvement. It had been recommended at the previous two inspections that residents should have some Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 12 involvement in this recording so that it provided an accurate summary of their day. This recommendation is repeated at this inspection. (See recommendation 4) Although there is a timetable of activities produced there was nothing recorded on the individual daily record to say whether the resident had participated, whether they had enjoyed it or whether they had been offered but refused to participate. (See recommendation 5) There was evidence that the residents’ health needs were being met as visits from health care professionals were recorded on a form held separately in the daily record file. This included visits from GP’s, chiropodist, optician, physiotherapist etc. The residents’ weight was being recorded consistently. The morning medication round was observed. The manager attends to the medication in the dining room at breakfast for those who chose to eat downstairs and the deputy manager attended to medication for those residents who took breakfast in their bedroom. The medication was in blister packs and was taken, together with the medication administration record (MAR) in a small basket to each location. This meant that the medication would not be left unattended and could be taken to each individual and signed for as they took it. Medication records were checked and were completed accurately. Medication was being stored appropriately in a lockable cupboard in the office. The residents spoken with all said that they were treated well by the staff. Staff were overheard interacting with residents appropriately and were seen to knock on doors before entering. Some residents choose to be called by their first name while others choose to be MR, Miss or Mrs. The staff approached each person with their preferred form of address. Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this area is good. This judgement has been made using available evidence and a visit to the service. The activities offered at Upton Grange would provide the residents with stimulation and exercise, which, together with a balanced diet, will promote healthy wellbeing. EVIDENCE: There are a number of activities held at the home each month. These are planned in advance and include, music and movement, beauty mornings, hairdresser, games mornings, film night (with a big screen being used) and a number of artists who call at different times each week to sing and play music. There is also a ‘shop’ held on alternative Sundays at the home for those residents who are unable to go out. A colourful leaflet is produced monthly with dates and times of activities and each resident is given a copy to keep in their room. Two residents spoken with in their rooms had a copy of the activities leaflet available. The manager should consider taking photographs of each activity so that the day’s activity can be displayed in a prominent position, in photographic form as well as in writing, for those resident who can no longer read. (See recommendation 6) Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 14 The residents confirmed that they could receive visitors at any time and there was a notice advising this on the notice board in the hall. Some of the residents are able to go out independently and go for walks around the local area. Two of the residents enjoy going walking around the grounds and local area together. Visitors arrived throughout the inspection days and some stayed with their relative in their room while others took them out for a while. The residents could have some control over their lives at Upton Grange. They were able to choose when they wished to spend time in their room and some residents were seen to do this during the two days of the inspection. There was a choice of menu available for lunch and residents were also able to choose whether they wished to participate in activities provided by the home. Residents were supported with daily activities at a level dictated by their assessment and care plan; this included them choosing what clothes to wear each day, choosing how and where they wanted to spend their time, making telephone calls to family and friends and choosing when to go to bed. All of the residents spoke highly of the food provided. The lunch on the first day of inspection was well cooked and presented. The breakfast on day two consisted of grapefruit, cereal, toast and jam/marmalade and tea or coffee. The residents spoken with said that they enjoyed their breakfast. One resident was spoken with in his room while he was taking breakfast and said it was just the right amount for him, it was very nice. Discussion with the chef and chef manager revealed that they have altered the menu to provide more variety, such as sea bass and fresh salmon. The chef manager said the residents are consulted after they have tried foods rather than before so that they can make a decision once they have tasted it. If it is popular it will be added to the menu. A new menu is devised for both winter and summer. The Chef also said that occasionally, and also for special events, she will make homemade pastries or the residents will be offered strawberries and cream in the garden if the weather is nice. Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this area is good. This judgement has been made using available evidence and a visit to the service. Ensuring all staff have received training in adult abuse awareness would mean that they would recognise all forms of abuse and be able to report poor practice. This would offer further protection for the residents. EVIDENCE: There had been one complaint made involving staff at the home since the last inspection. This was thoroughly investigated by Social Services, which included interviewing some staff and discussions with residents and their relatives. The complaint was unfounded. The Commission for Social Care Inspection was involved closely throughout. There have been no further complaints made since. The complaints procedure and details of who to address a complaint to are given in the Service User’s Guide and Statement of Purpose. There is also a copy of the complaint procedure on display in the hallway with details of the Commission for Social Care Inspection. There was a copy of the adult protection policy and procedure and the whistle blowing policy in the office. Staff who have completed NVQ level 2 or 3 will have covered some aspects of adult abuse awareness in their training. However, all staff, including new care staff, domestic and kitchen staff, should receive training in adult abuse awareness so that they can recognise the different forms abuse can take and report it. (See requirement 5) Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24 & 26 Quality in this area is good. This judgement has been made using available evidence and a visit to the service. Upton Grange provides the residents with a safe, homely, comfortable and well-maintained environment. This, together with the resident’s personalised bedrooms, will mean it feels like the residents’ home. EVIDENCE: Upton Grange was well decorated both inside and out. The quality of the furnishings was very good, in keeping with the period of the house and the expected lifestyle of the residents. There is a large lounge and a smaller lounge on either side of the main hallway. Additionally, there is a large dining room where some residents choose to remain after meals. All of the bedrooms viewed were well furnished and many rooms were large enough to provide the resident with an additional sitting area where they could watch their television or listen to the radio. The residents had also brought Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 17 some items from their own homes, including small items of furniture, ornaments and photographs. All of the bedrooms had en-suite facilities. In addition to the ensuite bedrooms there are a number of other toilets and bathrooms around the home. Equipment is available to enable the residents to remain as independent as possible in this area, such as grab rails, rise and fall bars next to the toilets. There is also a lift to the first floor for those who can no longer safely use the stairs. There was a routine programme of maintenance and the ‘handyman’ was observed repairing a damaged cupboard in the hallway. The grounds were also well tendered and made a safe, pleasant place for the residents to walk around or sit in the warmer weather. The home was very clean and there were no offensive odours. Two domestic staff were spoken with and showed the inspector the cleaning checklist that they followed in each room. It was clear from the appearance of the bedrooms, bathrooms and toilets that their work was very effective. Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the service. Staffing levels were sufficient to meet the needs of the residents and the deployment of staff ensured that there was no delay in the delivery of care to the residents. EVIDENCE: Four staff have left since the last inspection and two new care staff have been employed. Staffing rotas were checked and showed that there were adequate staffing numbers on duty on each shift to meet the needs of the residents. Staff were of varying ages and skills, some having completed NVQ Level 2 or 3, others nearing completion and newer staff receiving induction training. There was an induction training record which was showed through signatures from the staff member and manager, what areas had been covered and what areas were outstanding. This was also dated. The inspector sat in on the morning handover by the night staff. This was clear and the manager was observed taking notes of issues that arose from the handover. Staff were then allocated their work, with the manager taking responsibility for administering medication to those residents in the dining room and the deputy manager administering the medication to those residents who remained in their room for their breakfast. Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 19 Visitors, including the GP, had signed the visitor’s book on their arrival and staff were heard to request they did this if they overlooked it. Three staff files were checked, including the manager’s. The recruitment procedure was being followed, however, one staff file only contained one reference and certificates of training and qualifications were only held on the manager’s file. (See requirement 6) Discussion showed that the manager had a clear understanding of the Protection Of Vulnerable Adults (POVA) and the Criminal Records Bureau (CRB) and her responsibilities for ensuring these are completed before staff commence at Upton Grange. Both of the night staff were spoken with and both felt that they received adequate training, although they had completed much of it, including NVQ Level 2 when they worked at the home on days. Some of the staff training, including, first aid, health and safety, moving and handling was now out of date and there had been little training to meet specific needs such as dementia care and managing challenging behaviour. However, the deputy manager and manager said that they had been in touch with a local college who were prepared to offer staff training ‘in house’ and had asked them to put in order of priority the training they wished to receive. The manager said that dementia training, managing aggression and adult protection was amongst the list and had been prioritised by the staff. The training is likely to start in September 2006. Staff training must be kept up to date with refresher courses planned in advance to ensure this happens at the appropriate intervals. (See requirement 7) A staff training matrix might assist the manager to know who has had what training and when it is next due. (See recommendation 7) Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the service. The residents’ safety is assured through the regular health and safety checks conducted at the home. EVIDENCE: The manager has worked in the home for the past sixteen years and has successfully undertaken NVQ level 4 training. There is a questionnaire, which is completed by the residents on an annual basis. However, it does not have a date on it and also has a statement saying, ‘to be completed with the assistance of a member of staff’. There is also no report of the findings of the questionnaire published for the residents. It would give residents a greater opportunity to contribute their views of Upton Grange and the topics covered by the questionnaire, such as ‘How would you Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 21 rate attitude of staff, levels of care, etc if they were given the questionnaire and some time to complete it, either on their own or with a relative when they visit. There should also be the option for them to remain anonymous should they wish. The questionnaire could be expanded to seek the views of staff, relatives and other professionals who are involved in Upton Grange. A report of the collective findings, together with an action plan for any changes, or improvements that have arisen from the responses, should then be produced. (See recommendation 8) The manager continues to provide a ‘hands on’ approach and therefore is able to observe the practice of the other staff within the home. Following observation the manager said she meets briefly with the staff member to give them feedback as to their practice. It was clear from records that this was happening regularly and a form had been devised to record briefly the content of the observation and follow-up discussion. The staff member was also able to discuss anything that they wished during this meeting. Both the manager and staff member signed the record to say they agreed with the content. The two night staff spoken with said that the manager would also ‘drop in’ on them and conduct a supervision of their care practices. It would be beneficial if the staff training needs, knowledge of a chosen policy and procedure and care standards could be discussed and recorded at each meeting, as this would form a more in-depth supervision. (See recommendation 9) The manager is not responsible for the safe keeping of any of the residents’ finances. The resident’s family or their representative manages all financial arrangements and transactions for fee payment is made directly with the head office. Small sums of money for service users to pay for items such as hairdressing and newspapers are kept at the home. These are held in a lockable tin and receipts of all monies going out or in are held. The fire alarm was being checked weekly and there was a fire drill book completed by the home. There had been a full evacuation drill a few months before the inspection due to a faulty sensor. Although this had been a false alarm, the exercise had gone well. The last visit from Environmental Health did not raise any serious areas of concern. However, they did point out that many of the kitchen appliances were dated and could do with upgrading. Discussion held with the chef manager and chef revealed that attempts are being made by the Committee to raise funds for a completely new kitchen. The manager also confirmed this during feedback. Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 22 Regulation 26 visits were not being made to the home although there were regular visits made to the home by committee members and trustees. These were being recorded and included conversations held with the residents. However, the responsible individual for Upton Grange should make monthly visits to the home and record their views of the running of the home. The visit should check on health and safety matters, completion of documentation, medication records for accuracy, staff files, resident’s files and the views of staff, residents and relatives spoken with regarding the general running of the home. A report of the findings should be produced, a copy held at the home and a copy sent to CSCI. (See requirement 8) Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 23 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 3 3 3 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 X 2 Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? No Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 25 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 OP3OP7 Regulation 14 15 Requirement The resident or their representative must be involved in the assessment process and in devising their care plan. They, or their representative must sign all documents. A care plan must be drawn up immediately so that staff are aware of their role in meeting the residents identified needs. Care plans must be detailed to cover every aspect of the residents’ daily needs, including any specific instructions from health care professionals. Risk assessments must be provided to cover every aspect of the residents’ assessment where there is potential risk identified. All staff, including new care staff, domestic and kitchen staff, should receive training in adult abuse awareness The recruitment procedure must be followed and all necessary documentation for the protection of the residents must be held on the staff file. Staff training must be kept up to date with refresher courses planned in advance to ensure this happens at the appropriate intervals. DS0000006599.V292310.R01.S.doc Timescale for action 01/09/06 2 OP7 15 01/09/06 3 OP7 15 01/09/06 4 OP7 15 01/09/06 5 OP18 12 & 13 01/11/06 6 OP29 19 01/09/06 7 OP30 12 & 18 01/11/06 Upton Grange Version 5.1 Page 26 8 OP38 26 Regulation 26 visits must be made by the responsible individual on a monthly basis. The findings of the visit recorded and a copy sent to CSCI. 01/09/06 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 3. 4 Refer to Standard OP3 OP7 OP7 OP7 Good Practice Recommendations More detailed information should be gained during assessment if it is felt that the resident’s health and safety could be at risk. Staff should find creative ways of helping residents to continue to understand written documents. Where possible residents views on their day and the care they have received, should be sought and recorded on their daily record. The residents’ participation, or refusal to participate in an activity, together with the type of activity, should be recorded either in their daily record or separately in an activities file. All files should display a photograph of the resident. The manager should consider taking photographs of each activity so that the day’s activity can be displayed in a prominent position, in photographic form as well as in writing. The manager should consider devising a staff training matrix to show who has had what training and when an update is next due. Residents views about the way the home is being run should be sought without the involvement of staff and the availability for the resident to remain anonymous should be made. The views of staff and others involved with the home should also be sought and a report of the findings, together with an action plan, be produced. 5. 6. OP7 OP12 7 8. OP30 OP33 Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Upton Grange DS0000006599.V292310.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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