Care Home: Grosvenor Hall Care Home

What the care home does well There are good assessments and care plans in place to make sure that people’s needs and wishes are identified, and met in the way they want them to be. Staff treat people with dignity and respect, they are well trained and those spoken to had a good understanding of people’s needs, and they were observed helping people to be as independent as they could be. One person who had not been living in the home very long told us ‘I’m getting a good life now, these people are very friendly’. Staff encourage people to make their own choices and decisions, and to be as independent as they can be. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 There are good systems in place to make sure that people are protected, including robust recruitment procedures, staff training and up to date policies. Visitors are made to feel welcome and gave us positive comments about the care provided. One person said he comes everyday to have lunch with his relative and would give it a ‘5 star rating’. What has improved since the last inspection? Since the last inspection there has been lots of improvements to the environment. For example, an eleven bedded extension has been built with all rooms being decorated to a high standard and all having en-suite facilities. The garden has been improved for people with dementia, it has been made safe and has been designed for people to see and smell the flowers, plant their own bulbs or weed the raised beds if they choose. During the last inspection we said that there must be more meaningful activities especially for people who have dementia related needs and a new activity co-ordinator has been employed for 30 hours per week. Her role includes developing an activity programme to meet the individual interests and capabilities of people living at the home, however, there are improvements needed to make sure this requirement is fully met. We also said that an internal audit of the environment should be undertaken and this has been sent to us and details action taken and planned action. The care plan format has also been reviewed and changed to make the plans clearer and more detailed and refer to new laws about decision making. The complaints policy has been updated with our new name, address and telephone number, so that people can contact us if they need to. What the care home could do better: Although we found that lots of improvements have been made to the service people receive, we said that there are still things that the home must do to make things better. The Service User Guide must be up to date and should include information about the new laws regarding how people make decisions. A care plan must be written as soon as possible after the person’s admission using information obtained during assessments and/or local authorities to clearly identify the person’s needs and give staff clear action to take to meet their needs. Activities must be expanded and take into account individuals interests and capabilities. As well as the things we said the home must do, we made some suggestions to help make things better. We said that in order to make things safer for peopleGrosvenor Hall Care HomeDS0000061942.V376537.R01.S.docVersion 5.2there should be a more detailed risk assessment alongside general risk assessments already in place. Care plan reviews/evaluations should show us whether the person had been involved or had agreed with any changes made to their care We saw that the fire risk assessment had not been reviewed since 2007 and since that time an eleven bedded extension has been built. Although staff knew what action to take should the fire alarm sound the manager agreed to make sure this document was reviewed and updated accordingly. She also said that she is also going to talk to the local fire officer about timescales for updating the fire risk assessment. Key inspection report CARE HOMES FOR OLDER PEOPLE Grosvenor Hall Care Home Newark Road Lincoln Lincolnshire LN5 8QT Lead Inspector Elisabeth Pinder Key Unannounced Inspection 20th July 2009 09:10 DS0000061942.V376537.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grosvenor Hall Care Home Address Newark Road Lincoln Lincolnshire LN5 8QT 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) 01522 528870 grosvenor.manage@btconnect.com Mr Kanagasooriam Ravivaruman Anne Ruttle Care Home 40 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (40) of places Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of people who can be accommodated is: 40 2. Date of last inspection 2nd August 2007 Brief Description of the Service: Grosvenor Hall is a large two-storey, Victorian, listed building which is situated on a main road, south of the city of Lincoln and is within walking distance of local shops. Public transport is available to the city amenities. The home is set in its own grounds with a secure garden at the rear of the home. A patio has been constructed which provides an attractive, safe area for people to sit in. Car parking is available to the front of the building. The home provides nursing and personal care for up to forty people of both sexes, over 65 years of age, with an emphasis on providing care for people with dementia. Accommodation is on the ground and first floor. A lift gives access to the first floor. The home has undergone extensive renovation and refurbishment since the present owner purchased the property in 2004. The current fees range from £360.00 - £561.00 per week. Additional charges are made for hairdressing, chiropody, newspapers and personal toiletries. A copy of the last inspection report is available in the home. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use the service receive good outcomes. This was an unannounced visit and it formed part of a key inspection, focusing on key standards which have the potential to affect the health, safety and welfare of people who use the service. Throughout this report the terms ‘we’ and ‘us’ refer to the Care Quality Commission (CQC). The visit lasted just over six hours and took into account previous information held by us including the previous inspection report, their service history and records of any incidents that we have been notified of since our last visit. The Commission are trying to improve the way that we engage with people who use services so that we gain a real understanding of their views and experiences of social care services. During this visit we used a method of working where an ‘Expert by Experience’ visited the home as part of the inspection. An ‘Expert by Experience’ is a person who, because of their shared experience of using services, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The expert met and talked to people living in the home, visitors and staff. Before we made our visit the manager had returned the Annual Quality Assurance Assessment (AQAA). This gave us information about their own assessment of how well they are meeting standards and their plans to improve aspects of the service. We sent out surveys to people living at the home and to staff before we visited, however, at the time this report was written only one had been returned to us. The main method used to carry out the inspection is called ‘case tracking’, this includes following the care of a sample of people through their care records and assessing their care. We spoke to people who use the service and saw rooms of those who said we could and to two members of staff. What the service does well: There are good assessments and care plans in place to make sure that people’s needs and wishes are identified, and met in the way they want them to be. Staff treat people with dignity and respect, they are well trained and those spoken to had a good understanding of people’s needs, and they were observed helping people to be as independent as they could be. One person who had not been living in the home very long told us ‘I’m getting a good life now, these people are very friendly’. Staff encourage people to make their own choices and decisions, and to be as independent as they can be. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 6 There are good systems in place to make sure that people are protected, including robust recruitment procedures, staff training and up to date policies. Visitors are made to feel welcome and gave us positive comments about the care provided. One person said he comes everyday to have lunch with his relative and would give it a ‘5 star rating’. What has improved since the last inspection? What they could do better: Although we found that lots of improvements have been made to the service people receive, we said that there are still things that the home must do to make things better. The Service User Guide must be up to date and should include information about the new laws regarding how people make decisions. A care plan must be written as soon as possible after the person’s admission using information obtained during assessments and/or local authorities to clearly identify the person’s needs and give staff clear action to take to meet their needs. Activities must be expanded and take into account individuals interests and capabilities. As well as the things we said the home must do, we made some suggestions to help make things better. We said that in order to make things safer for people Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 7 there should be a more detailed risk assessment alongside general risk assessments already in place. Care plan reviews/evaluations should show us whether the person had been involved or had agreed with any changes made to their care We saw that the fire risk assessment had not been reviewed since 2007 and since that time an eleven bedded extension has been built. Although staff knew what action to take should the fire alarm sound the manager agreed to make sure this document was reviewed and updated accordingly. She also said that she is also going to talk to the local fire officer about timescales for updating the fire risk assessment. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Grosvenor Hall Care Home DS0000061942.V376537.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 Grosvenor Hall Care Home DS0000061942.V376537.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 is not applicable People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know about this service and are assured that their needs can be met due to a clear introduction and assessment process. EVIDENCE: Information sent to us prior to the inspection told us that people have access to a range of information about the service and are able to visit the home and spend time there before making a decision about moving in. Information is available in a Statement of Purpose and Service User Guide. The Service User Guide was not up to date and neither documents told people about the new laws regarding how people make decisions and the manager told us she would make sure all relevant changes are made to these documents as soon as possible. Information tells people how they can access a copy of the last Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 10 inspection report and tells them about the current fee rates and where they obtain independent advice should this be needed. The records of two people who had recently been admitted were looked at, one showed that a needs assessment had been carried out prior to their admission and information had been provided from a social worker for the other person who had been admitted in an emergency. Terms and conditions of residency/contracts and copies of letters confirming that after the assessment the service could/could not meet needs were on file. One person told the Expert by Experience that they had looked at nearly all the nursing homes in Lincolnshire before choosing this one and so far they were very satisfied. The service does not cater for people with intermediate care needs. Grosvenor Hall Care Home DS0000061942.V376537.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans assure people that their individual needs and wishes will be met in a respectful way. EVIDENCE: Since our last visit a new care plan format has been put in place and care plans are now written in the first person. We looked at the care plans of people being followed and these were clear and easy to follow. They contained information about how people want their care provided and the level of help needed, making choices and how they want their privacy and dignity to be respected. Records included, medical histories, appointments with other healthcare professionals, people’s preferences regarding male or female carers and some information about the person’s life, i.e previous lifestyle, hobbies and interests. Various assessments had been completed on subjects such as, nutrition, pressure risk and manual handling. A general risk assessment had been Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 12 completed identifying risks but these were not all supported by a detailed risk assessment and the manager told us this would be done as soon as possible. A care plan had not been written for one person admitted on 14th July 2009 and the manager told us staff were following a care plan from social services, however, this did not clearly identify the person’s needs or give staff clear action to take to meet their needs. Care plans are reviewed at least once a month, however, they did not tell us whether the person had been involved in their review or had agreed with any changes made to their care. Staff spoken to had a good understanding of people’s needs, and they were observed helping people to be as independent as they could be. One person who had not been living in the home very long told us ‘I’m getting a good life now, these people are very friendly’. The report written by the Expert by Experience read ‘residents were well cared for, helped but not forced. Those who could tell me said they did just what they wanted to, even if it meant staying in their room all day or eating alone’. A relative told the Expert by Experience that she was concerned about how her mother was settling in, but said staff had tried to make her room look like her room at home and they were very re-assuring to her. Medication is given to people by trained nurses and records looked at showed that medication procedures are followed in a satisfactory way. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are some activities and recreational events for people to participate in but these do not always take into account individuals interests and capabilities. Meals provided are well balanced and take into account personal preferences and dietary requirements. EVIDENCE: The provider has taken some action to address the requirement given during the previous inspection regarding the provision of more meaningful activities paying particular attention to people who have dementia related needs. A new activity co-ordinator has been employed for 30 hours per week and her role includes developing an activity programme to meet the individual interests and capabilities of people living at the home. We spoke to this person and she told us people liked hoop la and music. We received one survey prior to our visit and this read ‘activities are not always very variable and not all of the residents are included’. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 14 The report written by the Expert by Experience reads ‘activities were limited and poor’. We observed a very short interaction with a small group of people when a ball game was played. However, records showed that there are regular sessions of ‘music for health’, bingo, dominoes, hand manicures, and that people often go out in the garden which has been developed to enable people to be involved in planting and they are able to walk around independently in a safe enclosed area. A discussion was held with the manager, provider and area manager about the provision of activities and we were told that issues had been identified during supervision and action is being taken to address them. People told us that the food is ‘very good’, the chef has been working in the home for a number of years and has a good understanding of peoples’ likes and dislikes. Menus showed that a varied, nutritious diet is offered and people are able to choose each day what they want. The Expert by Experience reported that three people told her that they didn’t like eating in the dining room as ‘the good food was spoilt by some of the residents with more advanced dementia’. This was discussed with the manager who told us she would look into this and make sure people are aware of other dining areas. Visitors were seen to come and go throughout our visit and gave the Expert by Experience positive comments about the care provided. One person said he comes everyday to have lunch with his relative and would give it a ‘5 star rating’. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems within the home protect people from harm, and assure people that their complaints will be dealt with in the right way. EVIDENCE: Information taken from the AQAA tells us there are clear policies and procedures in place regarding complaints and safeguarding adults. The complaints policy is included in the Statement of Purpose and Service User Guide and is on display in the home. This was looked at during our visit and the procedure has been updated to include our new contact details. People told us that they feel safe living here and relatives told us that staff know how to keep people safe. Staff were able to tell us what they would do if they suspected or saw any kind of abuse happening and they confirmed they had received relevant training. The home has a copy of the Local Authority guidance on safeguarding adults and we know from our records that since our last inspection there has been one alert made to the Local Authority Safeguarding Adults Team. Records show that the manager and staff responded in the right way to the alert and have co-operated with investigations. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 16 People told us that they would feel comfortable speaking to the manager or staff if they have a problem and they feel that things would be dealt with quickly. Records showed us that no complaints have been made since our last visit. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well-maintained, clean, comfortable and homely environment. EVIDENCE: A partial tour of the building was carried out and we looked at some bedrooms of people whose care was being followed with their permission. These were clean, individualised with pictures, mementoes and ornaments. Bedroom doors did not have signs or pictures of the person whose room it was but pictures had been placed on bathroom and toilet doors and the manager told us some en-suite bedrooms have coloured toilet seats helping people with dementia needs find their toilet more easily and she is looking into providing memory boxes to place outside their bedroom. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 18 Specialist equipment is provided such as hoists and pressure relieving mattresses and the use of these was detailed in care plans. Staff told us they felt they worked in a safe environment and were observed using protective clothing when needed. Information taken from the AQAA told us that within the last twelve months improvements have included an eleven bedded extension, new lift, (large enough to accommodate a stretcher) and the development of a dementia garden. During our visit work was being carried out to open up the staircase. The manager told us that their Environmental Health Officer visited in June 2008 and awarded a five star rating. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected by recruitment procedures and a well trained staff team. EVIDENCE: We looked at staff records and these showed that application forms, criminal record bureau checks, identification and written references had all been completed before the person started work. Staff told us they had been given a good induction to the home and their training records showed that they had been given training in health and safety, moving and handling, fire safety, infection control and safeguarding adults. Over 50 of staff hold a nationally recognised care qualification and each person has a training programme in place which includes regular dementia training and the new laws around decision making. Staff told us they feel that there are usually enough staff on duty and they are able to complete their tasks without rushing. On the day of the visit 33 people were living in the home and duty rotas looked at for the past two weeks showed that there was generally five care staff and one qualified nurse on duty each morning and four carers and one qualified nurse each afternoon. Throughout the night there are two care staff and one qualified nurse. In addition to this there is a manager and an administrator. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 20 A survey received prior to our visit reads ‘the home has an excellent team of staff who take pride in the things they do. There is a good atmosphere around the home and staff enjoy their work’. The report written by the Expert by Experience identified that she observed staff being attentive to people’s needs and staff spoke to her about their indepth training programme. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 37 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and people’s rights are protected by good record keeping, policies and procedures. EVIDENCE: The manager has been in post since October 2008 and was registered with us in February 2009. She is a qualified nurse and has over eight years of management experience and has also obtained the Registered Managers Award. One questionnaire received prior to our visit read ‘we are led by a very good manager and area manager who are always there to support us,’ and during our visit no concerns were raised about the management arrangements. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 22 We were also told that the provider takes a keen interest in the running of the home and makes sure people have what they need to meet needs. One person said ‘he is the best I have ever worked for’. Staff told us that there is good team work within the home and they feel they are given the necessary guidance to complete their tasks. They told us they receive supervision from the manager and their records confirmed this. Discussion and records showed that there are various systems in place to monitor the quality of the service being provided. This includes seeking the views of people through meetings, questionnaires and relative surgeries. The results of questionnaires are included in the Service User Guide. Records showed that the provider regularly visits the home and the area manager completes a monthly report to show she continually monitors and evaluates how the home is running. Information provided in the AQAA told us that there is a good range of policies and procedures and the majority of these had been reviewed and updated this year. We were also told of equipment maintenance and service date. Building risk assessments are in place and the manager completed regular health and safety audits together with care plan and medication audits. The Department of Health ‘Essential Steps’ is used to assess infection control and records showed staff receive health and safety training. We looked at the fire risk assessment and saw that it had not been reviewed since 2007, however, staff told us they knew what action to take should the fire alarm sound and the manager agreed to make sure this document was reviewed and updated accordingly. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 24 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 OP12 Regulation 16 (2) Requirement Following consultation with residents, a programme of group and individual activities must be developed; to provide opportunities through leisure and recreational activities to provide residents with mental stimulation, paying particular attention to residents who have dementia related needs. This requirement has been met in part, therefore a further timescale has been given Timescale for action 30/09/09 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. Refer to Standard OP19 Good Practice Recommendations The Service User Guide should be up to date and include information about the new laws regarding how people make decisions. DS0000061942.V376537.R01.S.doc Version 5.2 Page 25 Grosvenor Hall Care Home 2. OP7 3. 4. 5. OP7 OP7 OP38 It is strongly recommended that a care plan is written as soon as possible after the person’s admission using information obtained during assessments and/or local authorities. More detailed risk assessments should be written to support the general risk assessment already in place. Care plan reviews/evaluations should show whether the person has been involved and has agreed with any changes to their care. The fire risk assessment should be reviewed and updated accordingly. Grosvenor Hall Care Home DS0000061942.V376537.R01.S.doc Version 5.2 Page 26 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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