Inspection on 06/10/09 for 4 Granville Road

This is the latest available inspection report for this service, carried out on 6th October 2009.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 Granville Road 28/04/08

4 Granville Road 16/10/07

4 Granville Road 05/06/07

4 Granville Road 13/12/06

4 Granville Road 09/12/05

4 Granville Road 05/05/05

4 Granville Road 21/07/04

4 Granville Road 04/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 15/02/2010.

Key inspection report CARE HOME ADULTS 18-65 4 Granville Road Reading Berkshire RG30 3QD Lead Inspector Yvonne Souden Key Unannounced Inspection 6th October 2009 1:30 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 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 home adults 18-65 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. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 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 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service 4 Granville Road Address Reading Berkshire RG30 3QD 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) 0118 959 9370 0118 959 9370 granville@paramounthousing.org.uk HVHS Housing Group Ms Denise Williams Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding learning disability or dementia (MD). The maximum number of service users to be accommodated is 9. Date of last inspection 14th April 2009 Brief Description of the Service: 4 Granville Road is situated in a residential estate approximately 2 miles from Reading town centre and provides residential care and accommodation for 9 people with mental disorders, excluding learning disability or dementia. The home is furnished and decorated to a basic standard; the building is owned by Reading Borough Council, and has been identified by Reading Borough Council and the organisation as requiring refurbishment. There is a large enclosed garden and parking facilities at the front of the house. There are 9 single bedrooms, 1 has a toilet and wash hand basin and the others have a wash hand basin only. There is no lift or stair lift and therefore the first floor would be unsuitable for wheelchair users or those who cannot manage stairs. 4 Granville Road has a Statement of Purpose and Service Users Guide available on application to the home. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The manager completed the homes Annual Quality Assurance Assessment (AQAA), which is a legal document provided, by the commission. The AQAA was used by the manager and provider to review their service and inform the commission of their findings. The AQAA was used as part of the evidence to inform this report. Other evidence used to inform the report included: • • • • A 6.5 hour site visit to the service by the inspector. This enabled the inspector to observe care practice and speak to people who use the service, staff and management of the home. Questionnaires sent by the commission and returned from people who use the service, staff and health and social care professionals that detailed their view of the service provided. Documentation viewed by the inspector on the day of the site visit. An ‘expert by experience’. An ‘expert by experience’ is a person who, because of their shared experience of using services, and /or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. What the service does well: The service provides a warm and welcoming atmosphere. People who use the service feel valued and respected by a staff team who are committed to meeting the needs of the residents, and keeping those residents safe. Residents have their health and social care needs assessed by health and social care professionals and by the home prior to their admission, and have those needs regularly reviewed. Residents mostly feel listened to, and feel confident that they can talk to staff if they have a concern about the service provided. Staff support residents to go about their lives attending daycare, work placements and activities within the community, however further improvement is needed to support those residents who have a physical disability, and to promote all residents independence within the home. Residents are supported to maintain a nutritionally balanced diet. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 6 What has improved since the last inspection? What they could do better: 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. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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 who want to live in the home have their needs assessed prior to their admission, and have their health and social care needs reviewed regularly following admission to the home. EVIDENCE: The manager of the home completed an Annual Quality Assurance Assessment (AQAA) as required by the commission. The AQAA said that people applying for placement are given a full assessment on admission to the home and said that prior to this assessments and risk assessment are completed by the person’s social worker and consultant psychiatrist. We looked at the individual needs assessments of three people who use the service. Assessments received from health and social care professionals identify the individual needs of the person, such as their mental and physical health care needs, cultural and social care needs. Assessments are reviewed regularly by health and social care professionals and by the service. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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): 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. Care plans are in the early stage of development and do not have sufficient detail to promote the persons independence and decision-making. Good detail of assessment and review are maintained. Risk assessments promote the safety of the people who live there within the decisions they have made, but assessment of risk are not always fully evaluated to minimise the risk. EVIDENCE: At the key inspection April 2009, we made a requirement that the registered persons must implement a system that ensures care plans and risk assessments accurately reflect the specific needs of all individuals living in the home and describe fully how they are to be met, to include where relevant, reference to the use of equipment for calling staff and the risk to those individuals if the call bell equipment is not available to them at all times. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 10 Records within each file viewed detail the assessed and changing needs of the person, and of how they are supported to make decisions within their lives, for example, risk assessments, assessment of need, Care Programme Approach (CPA) reviews, monthly evaluations and daily evaluation records. Care plans have not been fully developed to give a brief description of the person’s specific personal, social and health care needs and how to meet those needs. There is numerous documentation of assessment, risk assessment and review for staff to gain the information they need to safely meet the residents’ basic personal care needs, but this is time consuming for care staff, and creates a greater risk that an identified need is missed because it is not detailed in a brief plan of care. Discussions with new and existing staff evidenced an enthusiasm to reduce duplication, and to produce a care plan that is concise in describing the diverse needs of the resident and how those needs are to be met in agreement with the resident. Risk assessments have been updated to include use of equipment used by residents to call staff, and of the risk to those residents should access to the equipment be denied. We observed a demonstration of the call bell being sounded from a resident’s room. It was evident that no consideration had been given to the location of the call system that sounds within the staff sleep in room on the first floor. It is unlikely that staff would hear the alarm on the ground floor should a resident use the call bell for assistance, and therefore the risk remains high. See also section, Concerns, Complaints and Protection, and Conduct and Management of the Home. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 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. People who use the service are supported to maintain contact with family and friends, and are mostly supported to maintain their chosen lifestyle. Personal development with particular reference to those who have a physical disability is not supported within the home. EVIDENCE: At the last inspection April 2009 a health care professional said, A number of the residents have negative symptoms of schizophrenia - including loss of drive and motivation. Staff sometimes find it difficult to engage them in activities outside the home - because of emphasis on choice (e.g. if a resident refuses - they may simply respect this - where as the refusal may - be part of the symptom of the chronic schizophrenic illness - and the resident may benefit from a more assertive approach. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 12 The home employs a cleaner/rehabilitation assistant who has not attended mental health awareness training, and has had no specific training within rehabilitation, or specific training to deliver a varied activity programme to promote the independence of the residents’. The staff member works from 7 am to 1 pm, mainly to prepare and serve breakfast, and to complete domestic tasks. This leaves a limited amount of time for the person, within the role of rehabilitation assistant, to spend with residents individually or within group activities. The home has increased care support staff numbers to a minimum of two over twenty-four hours to ensure the safety of the residents, and to ensure the residents’ health and social care needs are met. At the last inspection, staff said that they did not have as much time as they would like to spend with residents on recreational activity or programmes of rehabilitation due to staff shortage. Since this date the staff complement has increased, and has greatly improved between the hours of 7 am to 1 pm and 4 to 8 pm. The rota identifies that between those times there are mostly 3 staff on duty. The home continues to use the service of domiciliary care staff to assist residents with personal care whilst staff, recently employed by the home, complete their induction. In response to the requirement April 2009, the provider said that residents’ activities are continuously reviewed and residents are given choice in what activities and social events they would like to attend. Most of the residents within the home are fairly independent and continue to say they are happy in the home and have a good relationship with staff and other residents. Records identify that residents are supported to visit family and friends, and that those residents who are physically able access areas of the home and the community independently and therefore maintain a lifestyle that mostly respects the choices they have made within a risk management framework. Those residents share in the responsibility of limited tasks within the home, for example, their own laundry and setting and clearing the tables at meal times. The expert by experience observed that this is an area that could improve particularly for those who are less independent. The expert said, “residents’ are not allowed to access the kitchen freely to participate within meal preparation, or to help themselves to snacks. This is an area that staff could improve to promote the independence of residents within daily living tasks”. Staff said that residents are unable to assist with food preparation due to poor food hygiene standards, and are unable to help themselves to snacks as some residents would eat obsessively. This is an area that could improve through risk assessment to minimise risk, and staff training to promote residents 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 13 independence. Staff prepare and cook all meals, and five out of eight staff have received food hygiene training. There has been some improvement to meet the social care needs of those people who are less able to access the community independently, for example the service has arranged for a resident, who is a wheelchair user, to have support to attend a day centre one day a week. Residents tell us that they want to go out more, but despite the increase of staff numbers, residents’ who are dependant on staff due to increased frailty are not properly supported to maintain a lifestyle within the home and community that promotes their independence around the choices they have made. The manager informed us that due to moving and handling constraints staff are reluctant to push residents in a wheelchair, and that this restricts the residents’ opportunity to be supported by staff in the community. Staff have not received moving and handling training. See section, Conduct and Management of the Home. With the recent improvement of staff numbers, the registered persons must ensure staff receive the training they require, that would include moving and handling to promote the independence and lifestyle of the residents who live in the home. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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): 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 who use the service receive support from staff to meet their health, psychological and personal care needs in a dignified and respectful manner. EVIDENCE: The home reviewed staff job descriptions, to include assisting residents with personal care in 2008, and secured funding in 2009 to employ extra care staff to reduce the use of domiciliary carers, and, to ensure the safety of the residents’ whilst meeting their personal, health and social care needs. People who use the service and who responded to surveys sent by the commission said that they receive the care and support they need. With an increase of care staff and better recording, it was evident that improvements have taken place to ensure people who use the service have their personal care needs met with dignity and respect. Staff were observed to 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 15 treat residents with respect, showing an interest in what individual residents had to say in a manner that was sensitive and caring. Records show that the service works closely with other agencies to ensure the residents’ personal and health care needs are met, for example, due to the continual frailty and physical disability of three residents’, assessments of their needs by health and social care professionals identify that the environment within Granville Road can no longer promote or meet the physical care needs of those residents safely, and therefore more suitable accommodation is being arranged. With exception to new staff and the rehabilitation assistant, all staff have attended training within mental health awareness, care of the elderly, personal care, medication, infection control and first aid. Refresher training within first aid and infection control for some staff is overdue and should be arranged. Only three staff have attended moving and handling, and their refresher training is overdue. The manager said that training would be scheduled for all staff as training becomes available via the Local Authority. The manager should be fully aware of the training needs of staff to schedule training in advance, as opposed to when due, and should not be dependant on one training provider when it is evident that the provision of training is not available at the time staff require the mandatory training. See sections, Staffing and Conduct and Management of the Home. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 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): 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. People who use the service are not listened to, but mostly know how to make a complaint should they have a concern. Policies, procedures and staff training at this home protect the people who use the service from abuse. EVIDENCE: The home has a complaint procedure. People who use the service say that there is someone they can speak to informally if they are not happy. Fifty seven percent of those people, who responded to surveys sent by the commission, said that they do not know how to make a formal complaint. A quality review report completed by a senior person within the organisation under Regulation 26 of the Care Homes Regulations identified that the service had received a complaint from a person who uses the service in May 2009, and that no action had been taken to bring the complaint to a conclusion. The manager could not recall the complaint, and no record had been made to show that the complaint was taken seriously within the timeframe of the services complaint procedure. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 17 The manager informed the commission on the 7 October 2009, that the complaint was passed to the provider for a response, confirming that to date no response letter has been received by the complainant. The service must detail a brief log of all complaints received, and give a brief account of the complaint, action taken and outcome with timescales recorded. The full record of complaint and outcome should be kept within the personal file of the person receiving support, and or within the care support workers personal record. This is to protect the confidentiality of the complainant and to ensure all complaints are taken seriously and managed within the timeframe of the complaint procedure. Staff said that they receive regular safeguarding adult training; training records viewed confirm this. Staff described what they would do if anyone was at risk of abuse, and were knowledgeable of up-to-date safeguarding policy and procedures kept within the home. Staff said they would not hesitate to protect the people in their care. The commission made a safeguarding referral at the time of the homes last inspection April 2008. A positive outcome was reached to safeguard residents within the home, but further improvement is required to ensure the call bell can be heard by staff if sounded. See, Individual Needs and Choices and conduct and Management of the Home. Since the last inspection there has been no further safeguarding adult investigations and no referrals made to the protection of vulnerable adults list (POVA). 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 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): 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. Improvements have been made to provide a safer, homelier and comfortable environment for the people who use the service, but further improvement would be required to ensure the layout of the building continues to meet the changing needs of the people who live there. EVIDENCE: There has been no change to the environment since the last inspection April 2009. The home had a wet room installed in April 2008 that improved conditions for those residents who require assistance with showering. The home was also redecorated at this time to a basic standard. Hot water outlets are regulated to ensure they are within safe temperature limits and procedures are in place to promote fire safety and infection control. At the time of this inspection the home was clean and fresh with no offensive odours. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 19 Although improvements have been made 2008/2009 to the environment to make it a safer and homelier place to live, it remains that further refurbishment is required to bring the home up to a good standard. Window frames are rusting and need replacing, adaptations, for example, the main call bell system is not positioned in a place that staff would hear if sounded by a resident who requires assistance, and there is no record of a planned maintenance and renewal programme for the fabric and decoration of the premises. Narrow corridors and lack of en-suite facilities may provide difficulties to residents’ and staff because of the changing physical needs of some residents, in particular those who have limited mobility and are wheelchair users. The provider informed the commission in writing in April 2008 that decisions with regard to major changes to fabric of the building have been delayed by the owners - Reading Borough Council. To date this remains unchanged. The narrow width of the corridors used by residents who are wheelchair users or require a walking frame remains a concern. Should any individual suffer a fall within one of the narrow corridors it would be difficult for staff to assist the resident safely with or without the use of a hoist. The home does not have a hoist to use within any area of the home and staff have not received moving and handling training. See Personal Health and Support, and Staffing. The registered provider must inform the commission of their arrangements with the local authority on how it intends to improve the standard of the care home’s environment to a minimum standard in order to meet the specific needs of the people living there. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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): 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 has a staff team who are caring, enthusiastic and sufficient in numbers to support and meet the needs of the people who use the service. The homes recruitment procedures protect the people who use the service. EVIDENCE: We saw at this inspection that staff were very caring and attentive towards the people who use the service, and that this contributed to a happy and homely atmosphere. The service continues to use agency care staff due to a shortfall of one full time carer. The manager does not request an update of the agency carers’ training profile and therefore was unable to confirm if the agency carers’ mandatory health and safety training was up to date, and if they had received training specific to the needs of the residents. See conduct and Management of the Home. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 21 The service continues to use domiciliary care staff to meet three residents’ personal care needs whilst new staff complete their induction training. Staff attend mandatory and specialist training to meet the specific needs of the people who use the service, but some mandatory training is not up to date. See Personal and Health Support and Conduct and Management of the Home. The manager should monitor staff training more closely to ensure refresher training is arranged in time for the scheduled renewal date. Fourteen percent of staff have a National Vocational Qualification (NVQ) in Care; this is an area that the service should improve to promote staff development, and to have at least fifty percent of staff with a care qualification. We looked at the file of two new carers employed. Records within each file demonstrate that the service follows a thorough recruitment process that includes a criminal record bureau check (CRB), and references from previous employers. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 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): 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. The manager is a caring manager who has the qualifications and experience to ensure the safety of the people who use the service and staff. Quality monitoring of systems in place to promote continual improvement of the service provided has not taken place to fully ensure the safety of the people who use the service. EVIDENCE: The homes Registered Manager Denise Williams is an experienced manager and holds an NVQ level 4. She is supported in her role by an assistant manager. There is a need for the organisation to ensure monthly Regulation 26 visits by the provider or representative are undertaken as an important part of quality assurance monitoring within the home, and as a positive step to gain the views of the service provided from the people who use the service. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 23 A requirement at the last inspection April 2009, said, ‘ The registered persons must implement a system that enables all people living in the home to contact staff in order to receive the help and support that they require, or in the event of an emergency, at all times of the day and night’. Action was taken to ensure residents have access to their call bell at all times, and that checks to ensure this is happening is undertaken by staff. The service should have a common sense approach to risk assessments. Having identified at the last inspection, the requirement for service users to have access to their call bells the service failed to recognise that the location of the main call bell system prevents staff from hearing the call bell when sounded unless staff are close to or in the sleep in room. This is an area that must improve when evaluating risk and to have an effective action plan to minimise the risk. Routine servicing and maintenance of equipment is undertaken at appropriate intervals to maintain the home as a safe environment, for example, fire equipment. The home has Health and safety policies procedures and staff attend health and safety training, for example, fire safety and infection control. Staff have not received training within moving and handling and staff training is not monitored effectively by management to ensure training updates are delivered when due. There was no evidence to demonstrate that the service had effective quality assurance systems to monitor the homes procedures, for example, the complaint procedure was not adhered to by the provider or manager as a complainant had been waiting five months for a response from the provider to a formal complaint that they had raised. See Concerns Complaints and Protection. Staff numbers have increased since the last inspection, April 2009, which has contributed to the safety of the residents, and to having their personal and health care needs met when required. The manager should improve records and resource management to make full use of care staff hours. Improved delegation of tasks could make a difference in the use of staff hours to implement a program of activity that promotes the independence and confidence of the residents and enables them to enjoy activities within the home and community, and must implement a structured quality assurance system that monitors procedures in place. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 1 X X 2 X Version 5.3 Page 25 4 Granville Road DS0000011054.V377932.R01.S.doc 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 YA22 Regulation Requirement Timescale for action 06/12/10 Regulation The registered persons must act 22 on concerns raised by people who use the service and respond Schedule to a concern raised within the 4 timescales defined in the organisations complaints procedure. The registered persons must keep a record of complaints raised with detail and dates of any investigation, action taken and outcomes. This is to make sure that people who use the service are listened to. 2. YA24 23. The registered persons must inform the commission of their arrangements with the local authority to improve the fabric and repair of the home’s environment to bring the home to a minimum standard of refurbishment and repair. This would include: • Replacement of window frames that are rusting. • Position of a secure call DS0000011054.V377932.R01.S.doc 06/12/09 4 Granville Road Version 5.3 Page 26 • bell system to make sure it can be heard by staff at all times if sounded by a resident requiring assistance Consideration of the narrow corridors and lack of en-suite facilities should the service want to provide a home for life for the people who live there. 06/02/10 3. YA39 24 The registered persons must implement a system for reviewing and improving the quality of care provided within the home to demonstrate year on year development of the service provided. This must include monitoring of: • Care plans to ensure they identify the assessed care needs of the resident and how those needs are to be met. • Risk assessments to ensure they are working effectively to minimise the identified risk. • Complaints to ensure people who use the service are listened to. • Staff training and monitoring of their development needs to ensure staff receive mandatory and specialist training when due, to include agency staff. The registered persons must ensure that completion of risk assessments consider all of the risk to make sure appropriate action is taken to reduce the risk. This must include where relevant reference to the use of equipment for calling staff, and DS0000011054.V377932.R01.S.doc 4. YA9 YA42 13.(4)(c) 06/11/09 4 Granville Road Version 5.3 Page 27 the risk to individuals if the system is not within an area that staff can hear if sounded. This is to ensure that the welfare and safety of the people who use the service are promoted. 5. YA42 13 The registered person must ensure all staff within the home receives moving and handling training, and refresher training. This is to ensure staff are competent, and to avoid injury to themselves and to the people who use the service. 06/12/09 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 YA13 YA16 Good Practice Recommendations The provider and manager should source information/training for staff that would inform them of activities that could be implemented within the home. This is to promote the lifestyle and independence of the people who live there. 2. YA13 YA16 The registered persons should make full use of staff resources to make arrangements that enable the people who live in the home to engage as fully as possible in local, social and community activities, and to use amenities within the local community according to their individual expressed wishes. See also recommendation 1. This is to enable people who use the service to pursue their chosen lifestyle and activities. 3 YA39 There is a need for the organisation to ensure monthly Regulation 26 visits by the provider or representative are DS0000011054.V377932.R01.S.doc Version 5.3 Page 28 4 Granville Road undertaken as an important part of quality assurance monitoring within the home, and as a positive step to gain the views of the service provided from the people who use the service. 4 Granville Road DS0000011054.V377932.R01.S.doc Version 5.3 Page 29 Care Quality Commission South East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.southeast@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). 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