Care Home: Grosvenor Mews

What the care home does well Before new people come to live at the home, the manager makes sure she has all the right details about them, so that he and they are clear that the home is the right place for them to live and that their needs will be met. A person who had recently moved into the home who told us they were "very pleased and surprised how nice it was." The residents at the home felt the care they received was good. Comments such as the staff are "really nice and kind" were made to us frequently. A relative spoken with said "it is extremely good with conscientious and caring staff. The staff have given my mother every help she ever needs in a caring and kindly manner". The residents` personal and health care needs were being well met. All the residents looked well cared for and if they were ill, the GP or district nurse is immediately sent for. When we have asked the Owner to investigate a complaint about care in the home we have received a prompt and detailed reply giving us the information we asked for. Meals and mealtimes were considered to be an important part of the residents` day. The dining rooms are nice places to sit, eat and meet with other residents. The residents said that they really enjoyed their meals. Residents were satisfied with the choice of meals and the way they were cooked and served. The home has an experienced and enthusiastic team of staff who work well together and enjoy taking part in training and development sessions. The staff are motivated and keen to ensure that residents receive high standards of care. The manager was experienced and ran the home well. She made sure she checked out staff before they started working at the home and gave them training and support to make sure they did the job to the best of their ability. Both residents and staff benefit from the home`s strong leadership and open management style. What has improved since the last inspection? Record keeping has improved a lot. The manager can now demonstrate more clearly to us the care provided at the home. Care plans are well ordered and easy to read. This makes it a lot easier for staff to keep up to date with residents` changing needs. New records are being used to check that residents with poor appetites are checked regularly and the staff take any action needed. Further progress has been made to make the home more homely with lounges being decorated and new furniture provided. What the care home could do better: A recent photograph of the resident should be included in their care plan so that identification is made easier for all the staff. When medication is hand written, they must ensure that a witness to the entry signs to say that it is correct. The Owner should assess whether there are enough staff working in the laundry to meet the amount of washing and ironing that is undertaken every day. There is a commitment to improve the environment and this should continue until all of the bedrooms have been refurbished. The last gas safety inspection certificate expired in June 2008 and therefore needs renewing. CARE HOMES FOR OLDER PEOPLE Grosvenor Mews Lancashire Hill Stockport Cheshire SK4 1RH Lead Inspector Bernard Tracey Unannounced Inspection 14th August 2008 07:45 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 Grosvenor Mews DS0000069122.V369404.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. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grosvenor Mews Address Lancashire Hill Stockport Cheshire SK4 1RH 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) 0161 480 4844 0161 429 0362 Grosvenor Care (Cheshire) Ltd Mrs D. Hardacre Care Home 50 Category(ies) of Dementia (50), Old age, not falling within any registration, with number other category (50) of places Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home with Nursing - Code N, to people 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: 50. 26th March 2008 Date of last inspection Brief Description of the Service: Grosvenor Mews is a purpose built home situated on a main road close to Stockport town centre. The home provides personal care for up to 25 service users accommodated on the ground floor. In addition, the home provides nursing care for up to 25 service users with dementia accommodated on the first floor. The majority of bedrooms are single en-suite. One double room is provided for couples or service users who wish to share. There are separate lounges and dining rooms, two ‘quiet’ lounges and a conservatory offering a variety of settings in which service users are able to receive visitors, socialise and participate in activities. The home is on a main bus route with a bus stop outside. There is ample parking for visitors’ cars. Fees for accommodation and care at the home range from £455.00 to £525.00 per week. Additional charges are made for hairdressing and chiropody services, newspapers and personal toiletries. Grosvenor Mews DS0000069122.V369404.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 the people who use this service experience good quality outcomes. We (the Commission of Social Care Inspection) undertook a key inspection, which included an unannounced visit to the home. The staff at the home did not know the visit was going to take place. The manager was asked to fill in a questionnaire, called an Annual Quality Assurance Assessment (AQAA), telling us what they thought they did well, what they need to do better and what they have improved upon. Where appropriate, these comments have been included in the report. Several weeks before the inspection, questionnaires were sent out to the staff at the home and we have received six completed forms. Service user questionnaires were left with selected residents during our visit but none have been returned. The questionnaires asked what people thought of the care and services provided by the home. We spent five hours at the home. During this time, we looked at care and medicine records to ensure that health and care needs were met and also studied how information was given to people before they decided to move into the home. A tour of the building was undertaken and we examined safety records to make sure that the equipment in the home was being serviced and checked on a regular basis. We also examined files that contained information about how the staff were recruited for their jobs, as well as records about staff training. We spent time speaking to four residents and a visitor, as well as speaking to the manager and five staff. We have received three complaints about the service. One referral has been made to the Social Services Safeguarding and is presently being investigated. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Record keeping has improved a lot. The manager can now demonstrate more clearly to us the care provided at the home. Care plans are well ordered and easy to read. This makes it a lot easier for staff to keep up to date with residents’ changing needs. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 7 New records are being used to check that residents with poor appetites are checked regularly and the staff take any action needed. Further progress has been made to make the home more homely with lounges being decorated and new furniture provided. What they could do better: 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. Grosvenor Mews DS0000069122.V369404.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 Mews DS0000069122.V369404.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. They are then able to confirm that they can meet the needs of the individual. EVIDENCE: Before any resident was admitted to the home an assessment of their needs was undertaken by a senior member of the staff from the home and by the professional, i.e., care manager, requesting their admission. The files showed that care management assessments had been completed by social workers. Two residents who hadn’t lived at the home for long said it was helpful to meet someone from the home before they moved in. Assessments held on file supported this. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 10 Potential residents and their relatives were given a copy of the Service User Guide either when they visited the home or during their assessment visit. The assessment documents of three residents were looked at. The assessments were detailed and gave a clear indication of the residents’ needs and their capabilities. The assessments looked at the physical, mental and social care needs of the residents, as well as the involvement, if any, of their relatives. We spoke with the relative of a resident who had been admitted from home. The relative stated that the manager had been out to the resident’s home to undertake an assessment of her needs. Feedback from discussion with residents indicated that they felt they had been given sufficient information about the home prior to moving in. Grosvenor Mews DS0000069122.V369404.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 The quality outcome in this area was considered good. This judgement has been made using available evidence, including a visit to this service. The care plans reflected the support needs of the residents. Care practices ensure that the residents health care needs were met, that they were treated with respect and their dignity was upheld. The medication system in place ensured that the residents received their medicines safely. EVIDENCE: Six care plans were examined in detail, three from the nursing unit and three from the residential dementia care unit. Good progress had been made since the last inspection in the development of care plans, including monitoring and reviewing arrangements. All contained comprehensive information relating to residents’ personal, social and health care needs. Daily entries in care notes were completed in all the plans examined. The plans were easy to read, had been regularly reviewed and set out clear guidance for staff to take when providing care. There was written evidence that the plans had been signed and agreed by either the residents or their representatives. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 12 The care plans examined contained some very good information in respect of residents’ past lives, needs, likes/dislikes and chosen lifestyle. For example, one read “likes three pillows” a second “likes to go to bed around 10.30 pm”. The residents and visitor spoken to were all very complimentary about the standard of care provided. For example, a visitor described the care as being “extremely good with conscientious and caring staff”. Comprehensive risk assessments were in place in all files examined. They covered areas such as nutrition, pressure areas, moving and handling, bedrails and falls. All had been reviewed, updated and audited by the manager on a regular basis. During the last inspection concerns were identified regarding the promotion and maintenance of residents’ health and access to health care services. Significant improvements have been made in this area. For example, individual records examined showed evidence of visits from General Practitioners, chiropodist, optician, tissue viability nurse, physiotherapists, dieticians, hospital consultants and community psychiatric nurses. Records also showed residents were now being weighed regularly and, where concerns regarding nutrition were identified, specialist advice had been sought. Feedback from the tissue viability nurse indicated a big improvement in pressure area care. She said staff requested visits promptly when concerns were identified. Progress had been made on improving the management of medication throughout the home. None of the residents on the dementia care unit selfadminister medication. All carers handling medication have completed medication training and are due to complete refresher training once a new examination date is set. One resident on the nursing unit is supported to selfadminister medication, all other medication is managed by qualified nurses. The pre-printed medication administration records (MAR’s) examined on both units were complete and up-to-date. Hand-transcriptions were not signed, checked and countersigned; some entries did not include the full dosage instructions, although the times had been indicated. Current guidance indicates that ‘there is no legal impediment to a care home constructing a handwritten MAR chart but that there is a potential for error when charts are regularly re-written’. It is recommended that all handtranscription is signed, independently checked and countersigned. The receipt of medication into and return of medication from the home was recorded. The medication storage was secure and orderly on both units. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 13 Relatives and friends are encouraged to visit as often as possible and the home operates an open visiting policy, which is referred to in the Statement of Purpose and confirmed in discussion with residents’ relatives at the inspection. A discussion with the residents identified that they feel their privacy is respected and that they are treated with kindness. Staff interviewed were able to describe good practice in this area. During our visit staff were seen to treat service users with respect and consideration, were attentive to individual needs and were discreet when providing assistance. Written evidence in care plans showed that residents’ needs in respect to dignity were considered important. Grosvenor Mews DS0000069122.V369404.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 Quality in this area was considered good. This judgement has been made using the evidence available, including a visit to the service. Social activities provide daily variation and interest for people living in the home. The dietary needs of the residents were well catered for with a balanced and varied selection of food being served. EVIDENCE: The choices residents made each day varied, dependent upon their mental frailty but residents generally choose what time to get up, go to bed, what clothes to wear, where to spend their day, what food to eat, whether to participate in activities. Overall, residents considered they were encouraged to do what they could for themselves and make appropriate choices through the day. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 15 The home has employed two staff with responsibility for the provision of activities. Positive feedback from residents, relatives and care staff were received regarding the increased provision of activities. The home gathers a social history, usually from the relatives, which is used to identify interests and hobbies previously undertaken by the resident. This social history is used to help to provide the staff with details and to encourage the individual to participate in appropriate activities. Residents told us that they are able to have visitors at any reasonable time and they can see their visitors in private. One relative told us that the staff at the home always made them very welcome. Records of food provided to residents confirmed that all receive a varied and nutritious diet. The residents were asked what they would like to eat and alternative meals are available. The food was served from a hot trolley that was brought through into the dining room. The tables were nicely set with tablecloths, napkins and cruets. Hot and cold drinks were served. The residents spoke positively of the food provided. The home should consider playing music during the meal rather than leaving the television on, to create a more relaxing background atmosphere We spent time talking with the care staff who clearly demonstrated their awareness of the appetites and preferences of each person and spoke of the need to present the meals in an appetising way. There was a choice of main courses and the chef confirmed that further choices were available from the kitchen. Residents said that they “really liked the food”. Snacks, such as pizza, toast or cheese and biscuits are available for staff to access during the period when the main kitchen is closed. Grosvenor Mews DS0000069122.V369404.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents were confident that complaints would be listened to, taken seriously and acted upon. Appropriate systems were in place to protect residents from abuse. EVIDENCE: There is a clear and accessible complaints procedure in place. Details on how to access the complaints procedure are widely available in the home. Since the last inspection good progress has been made in the way complaints made directly to the home are responded to. A system is in place for recording complaints. The home’s complaints book was examined and showed five complaints had been logged since the last inspection in November 2007. The complaints made directly to the home related to staff attitude and care practice. There was written evidence these complaints had been thoroughly investigated, including details of the steps taken to rectify the issues, and a copy of the report sent to the complainant. The concerns raised appear to have been resolved to the complainant’s satisfaction. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 17 Since the last inspection the Commission for Social Care Inspection (CSCI) received three complaints about the home. The complaints were investigated by the provider and overseen by the CSCI. One complaint related to lack of care, including personal hygiene, during a period living at the home. The concerns relating weight loss and health of resident when admitted to hospital were upheld. The remaining issues were unresolved. A second complaint raised anonymously related to several issues concerning care of the residents during the night hours. None of the concerns were upheld. The owner and manager fully co-operated in the investigation process. Residents and relatives indicated they felt able to approach staff with any concerns and these would be taken seriously. None of the residents had made a complaint but all indicated they were aware of how to do so if the need arose. Grosvenor Mews DS0000069122.V369404.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home has a planned maintenance and renewal programme for the redecoration and refurbishment of the home to ensure residents live in a comfortable, homely and safe environment. EVIDENCE: The home is generally well maintained both internally and externally. On each floor of the nursing and dementia care units are lounge/dining areas. These areas are nicely decorated and furnished with good quality items, providing residents with attractive, accessible and safe areas where they can sit. Some redecoration has taken place but large parts of the corridors and most of the bedrooms require decoration. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 19 The manager informed us that there is a planned maintenance and renewal programme for the re-decoration and refurbishment of the home. A maintenance worker and decorator were employed and staff and residents said they addressed matters as they were raised with them. A tour of the home confirmed that the home was generally well maintained, clean and free from any offensive odours. Ramped access was provided to the front door and level access throughout each of the two floors. A passenger lift was provided and handrails fitted to corridors throughout. Everyone spoken with thought the home was a safe place to live and work in. Some progress has been made in improving signage and orientation aids on the dementia care units. For example, some toilet doors have been re-painted red which research has found to be a useful aid to orientation. Further improvements are still required in order that residents living with dementia have a supportive environment, such as improved signage. For example, toilets could show a picture of a toilet. Grounds were seen to be safe, tidy and accessible. Residents said they looked forward to sitting outside in the good weather. Four residents spoken to were very pleased with their individual rooms and said that they had “brought in a number of personal possessions, pictures of grandchildren and family and other things that help remind me of places I have been”. Residents said staff kept the building clean and odour free, inspection of the premises supported this view. Discussion with two domestic staff verified that sufficient staff and equipment were provided to ensure the home was maintained in a clean and hygienic condition. An infection control policy was in place and training was provided in this area. Staff spoken with described safe infection control practice. Satisfactory practice was in place with regard to disposal of clinical waste. The laundry is situated in the basement and was well equipped with two large industrial washers with sluice programme and two driers. The laundry staff felt that there were not enough assistants employed in the laundry to cope with the workload. The owner has said that a new laundry will be built in the future with more capacity but in the meantime it is recommended that a review of the laundry operation be undertaken with a view to increasing the number of staff employed there. Grosvenor Mews DS0000069122.V369404.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There are appropriately trained and experienced care staff employed so that residents feel supported and that their needs are understood and met. The home’s recruitment policy is generally robust to protect the residents. EVIDENCE: The staffing rotas for the month of July were viewed along with the current rotas. Sufficient numbers of staff were on duty at the time of the site visit to care for the residents and the staff team comprised of seven care staff, one Registered Nurse, the manager, a maintenance man, domestic and catering staff. The home has a stable workforce and a number of staff have worked at there for many years. No new permanent care staff have been appointed since the last inspection and outstanding shifts are filled by existing or bank staff but during holiday periods Agency staff may be used. Staff were complimentary regarding the support they receive from the manager. Residents interviewed described the staff as “Caring”, “Helpful”, “Polite” and all the members of staff support us and each other in a very caring way”. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 21 The home has a rolling programme for staff training and a training plan viewed evidenced courses attained in safe working practices including, fire prevention, manual handling, infection control, first aid and health and safety, Dementia care and the Protection of Vulnerable Adults. All the staff have attended abuse awareness training and other courses relevant to the older person. The selection procedure includes obtaining two written references and a formal interview. All staff had enhanced CRB disclosure checks. Upon appointment staff are issued with a handbook, which includes job descriptions and terms and conditions. Appointments are subject to a six-month probationary period. A sample of staff files were examined and these contained all the relevant documentation and were clearly sectioned and well-organised. These are all good practices and ensure that a carefully selected and vetted staff team supports residents. Grosvenor Mews DS0000069122.V369404.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The registered manager provides guidance and support to staff, ensuring that the residents receive a consistently high standard of care, and to ensure the home is run in the best interests of the residents. EVIDENCE: The manager is a qualified nurse who has many years’ experience in caring for residents and intends to study for a management qualification. Throughout the inspection we were able to observe the professional, capable and approachable manner in which the manager undertook her role when dealing with residents, staff and visitors. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 23 There are good systems in place to gather staff, residents and relatives’ views as part of the monitoring of quality. Staff spoken to had a clear understanding of their role and what was expected of them. Residents, relatives and staff spoke well of the management team and the care and support that they give. The inspector was able to witness their approach to the residents and staff and confirm the comments made. Information provided by the manager and examination of the records confirmed that all safety equipment is regularly serviced, although the annual Gas Safety certificate was overdue by six weeks. The manager undertook to arrange for this inspection to take place as soon as possible and to forward a copy of the gas inspection to the Commission when completed. The policies and procedures in the home ensure that the health, safety and welfare of the residents and staff are promoted and protected. Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 24 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 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 X 3 X 3 2 X 3 Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP38 Regulation 16 (2) (g) Requirement The annual service and gas safety check must be undertaken to ensure the safety of people living in the home. Timescale for action 30/09/08 Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 26 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 Refer to Standard OP7 OP9 OP27 Good Practice Recommendations The manager should ensure that all care files contain a recent photograph of the resident to ensure correct identification of the individual. Hand transcribed medications should be witnessed by two members of staff to avoid errors. The manager should ensure that sufficient staff are available in the laundry to ensure an effective and efficient service to the residents is maintained. The current programme of refurbishment should be completed as soon as possible to improve the environment for the residents. A programme of formal staff supervision should be introduced so that staff have the opportunity to meet with their supervisor on a regular basis and discuss their job role. 4 5 OP19 OP36 Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Area Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Grosvenor Mews DS0000069122.V369404.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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