Care Home: Harton Grange

Similar services:

• Turret Villa Retirement Home
• Mendip House
• Beaconsfield Court Care Home
• Little Sisters Of The Poor
• Manor House
• Middleton Hall Ltd
• Middlesbrough Intermediate Care Centre

What the care home does well What has improved since the last inspection? The Statement of Purpose and Service User Guide have been updated to reflect the changes in management in the home. People are given a copy so that they have current information about the home and the service delivered. The new assessment records are now completed in detail. And the registered manager now confirms in writing that the home can meet individual needs. Fire doors are now only kept open by mechanisms that are connected to the fire alarm system. CARE HOMES FOR OLDER PEOPLE Harton Grange Boldon Lane South Shields Tyne and Wear NE34 0LZ Lead Inspector Irene Bowater Key Unannounced Inspection 8 &15 May 09:00a 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 Harton Grange DS0000069206.V363892.R02.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. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harton Grange Address Boldon Lane South Shields Tyne and Wear NE34 0LZ 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) 0191 4546000 0191 4546002 lesley.gregg@barchester.com www.barchester.com Barchester Healthcare Homes Ltd Lesley Gregg Care Home 61 Category(ies) of Dementia (31), Mental disorder, excluding registration, with number learning disability or dementia (31), Old age, of places not falling within any other category (61) Harton Grange DS0000069206.V363892.R02.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 only - Code PC 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, maximum number of places 61 Dementia - Code DE, maximum number of places 31 2. Mental Disorder - Code MD, maximum number of places 31 The maximum number of service users who can be accommodated is 61 10th May 2007 Date of last inspection Brief Description of the Service: Harton Grange is a care home offering personal care to 61 older people, some of whom may have dementia, mental health needs or a physical disability. Situated just off a busy main road, the home is a short walk from local shops and other amenities. The local library is next door and shares the same access road. The home has 3 floors, although residents use only 2 floors, as the 3rd floor provides staff facilities. All the rooms are single, meet National Minimum Standard sizes and benefit from en-suite toilet facilities. A choice of lounges is available and lobby areas were designed to provide additional seating areas and are popular with residents. Access into the building is level and a shaft lift provides access to the other floors. A door entry system is operated on the front door as a security measure. Externally, an enclosed garden area can be accessed via the ground floor but residents on the first floor also have access to a balcony area. The home has developed a Service User Guide that offers information about Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 5 the home and the service offered for service users and other interested parties. The current fees charged by the home are between £395 and £425 per week. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means that the people who use this service experience excellent quality outcomes Before the visit: We looked at: • Information we have received since the last visit on 10 May 2007. • How the service dealt with any complaints and concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service and their relatives, staff and other professionals The Visit: Two unannounced visits were made on the 8 and 15 May 2007 totalling 11.5 hours. As part of the site visit we gathered additional information about how the home safeguards the people who use the service. A separate pharmacy visit also took place on the 13 May 2008 and took 5 hours to complete. During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors • Looked at information about the people who use the service and how well their needs are met • Looked at other records which must be kept • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for • Looked around the building to make sure it was clean, safe and comfortable • Checked what improvements had been made since the last visit • We told the manager what we found. What the service does well: Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 7 The staff collects information together about the person before anyone moves into the home to make sure they can meet their needs. A great effort has been made by the home to gather as much background information about individual service users as possible. This has now become standard practice and includes past events and routines linked with individual/s lives. This information is used to produce detailed and up to date care plans. Staff are trained well so that they understand the needs and behaviours of people, which in turn promotes their well-being. The home supports people with dementia and other illnesses related to memory loss extremely well. The dementia care unit is particularly well organised and furnished with stimulating objects and activities that attract service users and engage their interests. Staff are friendly and have a good relationship with people who use the service, families and other professionals. The service is busy and there are activities everyday if people want to join in. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. The home has a good standard of decoration and furnishings. All bedrooms are a good size and all have their own private en-suite toilet. Lounges are comfortable, warm, bright and cheerful. Bathrooms are also well decorated and warm. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The registered manager makes sure that all checks and clearances are received before staff are employed. Staff training is good with over 70 of staff having achieved NVQ level 2 or 3 so they are trained to support people in the right way. People who use the service and their relatives are able to say what they think about how the home is run which helps them to have control over their lives. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. And the registered persons make sure that the home is a safe place for visitors and those who live there. Comments from relative surveys sent out by the Commission included: Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 8 “The individual personal touches are quite over whelming. A lot if thought has gone into providing a stimulating, appropriate environment”. “Nice atmosphere “alive with chatter.” “It is clean and homely, the staff are friendly and know the residents and visitors well.” “I visited the home about four years ago and it is now a completely different place. It is now a wonderful happy home.” “I hope there is somewhere like this if I ever need it .A gold standard – All care homes should be like this.” “I visit at different times and the standard of care is very good. The home is well run in my opinion.” “The food is excellent and we often have a meal with X.” “There is a new member of staff who provides different activities every day and I feel much happier knowing A is busy and enjoying her days.” “The staff do an excellent job and arrange doctors visits when necessary.” “In my experience it is nice to see each resident treated as an equal adult”. “My family have peace of mind knowing that Y is well cared for.” What has improved since the last inspection? What they could do better: The requirements and recommendations from the Pharmacy Inspectors visit must be actioned within the timescales given. The registered manager and the staff team should continue to develop the home in line with current best practice . Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 9 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. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 10 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 Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 11 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): 1, 2, 3 &4. Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good systems ensure that detailed information is made available to people about the home and comprehensive assessments of need take place which, helps people to make the right decision about using the service. EVIDENCE: The home sets out the aims and objectives of the service in a Statement of Purpose, which is readily available. There is also a Service Users Guide that sets out the values of the home. This makes references to supporting the diversity of needs, cultures, and beliefs of all those involved in the home. Everyone who is admitted to the home is given a “Welcome Pack” which gives a clear account of what to expect whist living in the home. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 12 Before anyone is admitted to the home a full needs assessment is undertaken by a Care Manager and the Home Manager. The pre-admission assessments were detailed providing information about peoples personal care, life history’s preferred routines, social activities and cultural needs. This information is then used to complete a plan of care for the individual living in the home. Since the last visit people are told in writing that the home can meet their assessed needs. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 13 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care is well planned and delivered in a respectful and person centred way. This enables people to fully access healthcare and other services and ensures there needs are fully supported. EVIDENCE: Since the last visit to the home the staff have continued to improve the care plans. Plans are person centred and look at all areas of a person’s life. The information includes risk assessments for prevention of falls, nutrition, pressure ulcer prevention, moving and handling and continence care. These assessments identify what action should be taken to support the individual. Care plans are in place covering such issues as personal care, mobility, daily living and communication. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 14 Staff have taken the time to find out about previous life histories including, “enjoys football”, “loves music and singing” and “likes to sit in the sunshine in the garden”. Another care plan shows how the staff supports an individual to maintain links with family so that so the they “don’t fret”. This type of information is important to make sure that individuals receive person centred care whilst in the home. The care plans show that staff work with individual’s and their families so that they can maintain their independence for as long as possible. People living in the home have full access to all health services including, GP’s dental, ophthalmic and chiropody services. The home also has good contact with district nursing services and asks the advice of specialist health care professionals such as dieticians and when required. Staff involve other professionals in the provision of care. Weights are regularly recorded and, should there be weight loss or difficulty with eating or drinking, a referral is made to the GP and to speech and language therapists. Copies of the company medicine policies are in the office and in medicines room attached to the trolley. These are supplemented with some local policies for the home, which are not dated and contact details for pharmacy, oxygen supplier etc are left blank. There is no local policy for waste disposal as required by the company and no record seen to demonstrate that staff have read and understood the policies. No one currently self medicates. The senior carer gave out the 9am medications and had been assessed by the manager as competent to administer medicines. There was some obvious good practice such as wearing of a distinctive tabard to reduce interruptions from other care staff. Good encouragement and support was given to assist with taking medicines and plenty of drinks were available. There was a lot of handling of medication without gloves and not handling via no-touch technique Medicine Administration Records (M.A.R) are kept in ring binders, two for ground floor, one for first floor. The files are generally well maintained with dividers bearing photo, room number, allergies and personal details of resident. One chart was loose and another had a photograph missing There was an up to date register of staff who are authorised to administer medicines. Handwritten entries on the M.A.R generally have two signatures Quantities of medicines received, date received and quantities carried over from previous month are nearly always recorded but not so for as required medicines. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 15 All medication is stored securely. The room was cramped, untidy, very cluttered and evidence of being used as rest room. There was lots of loose paperwork around a small bench top together with large filing cabinet housing old MAR charts and diabetic equipment. Medicines trolleys were secured to wall and clean but one was very full and insufficient space to hold all MDS stock in ring files. The Medicines cupboards and fridge although lockable were not locked. It was difficult to locate individual supplies of drugs in cupboard under bench because of a large volume of medicines stored alongside blood testing strips etc. Some medicines for return to pharmacy were in a cupboard that was not locked. An audit of three Controlled Drugs (CD) found all entries legible and accurate. A second signature and date is not being included when CDs taken into stock There were no dates and signatures for disposal of some Controlled Drugs from last year. No date was available for destruction of diamorphine injection but two signatures were recorded Entries are also made in drugs for disposal book but we could not find an entry for one CD.There are no regular CD stock checks although the policy says it should be weekly. Good systems are in place for recording all training, including medicines management training. Information is on a wall chart, which can be crossreferenced to individual staff files. All carers handling medicines have received accredited training and have been subsequently assessed by manager/deputy manager as being competent. There are good working relationship with local pharmacy and the pharmacist comes in two or three times a year. Internal auditing is carried out regularly by manager or deputy. All of the staff had a good understanding of individual needs and were alert to changes in people’s mood and behaviours and made sure that support and assistance was given in a discreet sensitive manner. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 16 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 outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Opportunities to take part in meaningful activities and keep control of everyday decisions are excellent. And people are given the opportunity to lead full and active lives. EVIDENCE: The manager has recently employed an activities organiser for the home .She was very busy organising different activities for groups and individuals throughout the day. Care staff also encourage and support people to take part in daily activities that they choose. An activities programme displayed in the entrance hall informs everyone what is planned for the week ahead. There is a vast range of activities including pamper days, tile painting, board games reminiscence, music and local history. A working kitchen has been developed on the first floor where people can go with support from staff or relatives to bake bread and cakes, while at the same Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 17 time to rekindle old skills and maintain independence while carrying out domestic chores. The staff at the home have developed strong links with Beamish Museum and the staff use ideas and information to provide stimulation especially for those with memory loss. There are rummage boxes, individual memory lane boxes for each person, touch and feel pictures on the walls and a mural. Upstairs there is an old market cake stall and one room is being changed into an old-fashioned tearoom. Hat stands have a variety of hats and bags which some of the people enjoyed trying on and wearing for a short time. Different theme nights are organised to encourage visitors into the home. Events that have taken place have included Fish and Chip, Cheese and Wine and Curry nights and staff were busy organising a trip to the theatre. There are also regular outings on the mini bus. One person said she “had a lovely time at Marsdon”. Stimulating objects and pictures decorate the home. Pictures of old film stars and entertainers decorate the walls and murals made out of materials that can stimulate the mind when touched are available for people to stop, look at and feel. There is a large extremely pleasant accessible garden which several people enjoy using. This are is also being developed to provide a sensory garden and there are plans to erect a bandstand. While upstairs there is a large safe balcony which people can easily access. Several people enjoyed sitting in the sunshine watching the activity in the street below. The people living in the home are able to enjoy a stimulating and varied lifestyle based on their previous lifestyles and interests There are dining rooms on each unit. The tables were nicely set with appropriate tablecloths, condiments, crockery and cutlery. Choices were available for the lunchtime meal and hot and cold drinks were always available. Large jugs of iced lemon water and bowls of fresh fruit and “finger foods” were freely available. Support was given in a discrete sensitive manner and the mealtime was flexible, relaxed and unhurried. One family said “we often have a meal, the food is excellent and there is always lots of choice”. Other comments included, “My meals are always good” and “we get plenty to eat and drink”. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 18 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. Good complaints and protection systems are fully understood and followed. This makes sure that people are able to express any concern and they are protected from harm. EVIDENCE: There is a detailed complaints procedure, which clearly sets out how and to whom to make a complaint. The procedure is available in the Statement of Purpose, Service User Guide and is displayed in the home. The philosophy in the home is to address any concerns straight away and make sure that they are sorted out quickly and to everyone’s satisfaction. There have been two complaints since the last visit, which have been, resolved at home level. Visitors said “We would be able to make any concerns known and we have had meetings with the manager to put things right”. Staff are trained in Safeguarding Adults procedures so can recognise abusive situations and would know what to do if they suspected abuse. There is also written information and guidance, as well as policies and procedures available in the home for staff to look at if they need further guidance. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 19 There are clear systems for staff to report concerns about colleagues which is in line with local policies and staff said they knew they would be supported if they “blew the whistle” on bad practice. The administrator and manager only have access to the records and monies. Personal monies are kept by the home for named people only and all other financial transactions are conducted through individual bank accounts and the Company finance department. Clear and audited accounts are kept of all individual financial transactions. Money spent is confirmed with receipts and entries on to individual records and witnessed with two signatures. All rooms have a lockable facility should anyone wish to keep their money and other valuables safe. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This home is decorated and furnished to an excellent standard. It is clean, warm and well-maintained offering people a homely, stimulating and safe environment in which to live. EVIDENCE: Since the last site visit several of the communal areas have been redecorated and the refurbishment of the reception area and a lounge has been approved. The garden has been developed, there has been refurbishment in the quiet room upstairs, a working kitchen is now available on the upstairs unit and a tearoom is being developed on the ground floor. New lighting has been Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 21 provided in the reception and all gloss paintwork painted white to make the environment bright and homely. There are extensive gardens and an accessible balcony on the first floor, which are safe and easily accessible. The communal areas were nicely decorated and furnished. And the manager and staff have put an enormous amount of effort on making the dementia care unit more stimulating and appropriate to the needs of the people who live there. People who live here are now occupied in meaningful activity in an environment that is interesting, accessible and suited to their needs. Pictures and small pieces of memorabilia decorate the surroundings. This helps to provide reminiscent experiences, while at the same time providing an environment where people feel safe and secure. For example, a small room has been converted into a comfortable old sitting room where service users can go to spend some quiet time. This is set out with an old fireplace and period furniture to match. It is an area where people may wish to relax and reminisce. This was also the one area in the home where there was an odour of urine. Since the visit the manager confirmed that this has been investigated and appropriate action has been taken to stop any further smell. All bedrooms have an en-suite facility and there are bathrooms and toilets close to all areas. Bathrooms and shower rooms have plenty of aids and adaptations so the people can use these facilities easily and safely. The laundry area is well–equipped, organised and clean. Staff were able to discuss infection control procedures and were observed to follow them at all times. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 22 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. Staffing levels and systems around recruitment, selection and training of staff are good and meet the range of needs of the people using the service and protect them from harm. EVIDENCE: The registered manager makes sure that there are enough staff on duty to support the people who live in the home. During the day there are nine staff on duty and overnight there are five waking staff. There are senior care staff on duty at all times and both the registered manager and deputy manager are supernumerary. There are sufficient ancillary staff including domestic, administration, and cook and kitchen assistants. A successful recruitment drive was initiated and resulted in the home no longer using agency staff. Five staff files showed that a suitable application form had been used. Two references are obtained and Criminal Records checks are always carried out before anyone is employed. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 23 New staff have an induction period and are given a staff handbook, which sets out clear standards about all areas of employment. Mandatory training for moving and handling, fire prevention, first aid, and infection control and food hygiene is up to date. People who live in the home have different health care needs, for example, they have had a stroke, have poor nutrition or have dementia care needs. Staff have up to date records to show that they have completed specialist and National Vocational Qualification (NVQ) training. Staff said they “always had plenty of training” and “I had a good induction so that I knew how to look after people properly” Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 24 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, 32, 33, 35 & 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is run by a competent manager who makes sure that good quality assurance and safety systems are in place. This makes sure that people receive an excellent safe quality of care. EVIDENCE: The manager has been registered with the Commission for Social Care Inspection. She has also completed the Registered Managers Award, is an NVQ assessor and has a National Vocational Qualification (NVQ) level 4 in care. And she is experienced and has made changes, which has improved the quality of the service. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 25 The manager is passionate about the work she does and works alongside the staff to constantly improve and develop the service. There is an atmosphere of openness and respect in the home and everyone said they would be able to discuss any issue with her There are minutes of staff meeting where staff are encouraged to discuss a variety of topics and anything that is causing them concern, the relatives and residents are encouraged to use these meetings in the same way. There are detailed quality assurance systems in place that is monitored by the Company. These include nutrition and meal times, care planning, infection control and health and safety. The home has also achieved the Investors in People Award. All mandatory training was up to date. Health and safety risk assessments are clear and kept up to date. Accidents are recorded and best practice guidance is used to track trends, which prevents as far as possible the same accidents occurring. Internal maintenance checks are up to date and external service certificates are available and up to date. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 26 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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 X X 4 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 4 4 4 X 3 X X 4 Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 27 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 OP9 Regulation 13(2) Requirement The registered persons must ensure that medication be stored securely and safely and in line with any legal requirements. This will prevent any tampering with medicines and possible theft. Medication must be given as prescribed and a record made at the time that it is given. This will make sure that people receive their medication correctly and the treatment of their medical condition is not affected. Best practice guidance and the providers current procedures must be followed when medicines are received into the home and when giving and recording medicines. This will help demonstrate that medicines are being given as prescribed thereby protecting the health of individuals. Handwritten entries and changes to MAR charts must be accurately recorded and detailed. Entries should be signed, dated Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 28 Timescale for action 01/07/08 and countersigned by a witness to reduce the risk of error when copying information. This makes sure that the correct information is recorded so that the person receives their medication as prescribed. 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 OP9 Good Practice Recommendations The medicines policy should be updated in line with the contractors guidance so that staff understand all aspects of how to handle and administer medicines safely. A system should be in place to record all medication received into the home and all medication carried over from the previous month. This helps to confirm that medication is being given as prescribed and helps when checking stock levels. The receipt and disposal of all controlled drugs should be fully recorded in the controlled drug register including the date and signatures of the staff involved. Stocks of controlled drugs should be regularly checked and a record of the check made in the controlled drug register. Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Harton Grange DS0000069206.V363892.R02.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!