Inspection on 19/02/08 for 136 Grovelands Road

This inspection was carried out on 19th February 2008.

CSCI found this care home to be providing an Poor 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

136 Grovelands Road 10/07/08

136 Grovelands Road 28/02/07

136 Grovelands Road 25/01/06

136 Grovelands Road 07/09/05

136 Grovelands Road 25/01/05

136 Grovelands Road 04/08/04

136 Grovelands Road 09/03/04

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Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 136 Grovelands Road Reading Berkshire RG1 7LP Lead Inspector Yvonne Souden Unannounced Inspection 19th February 2008 2:30 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 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 136 Grovelands Road DS0000011064.V357607.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 Adults 18-65. 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. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 136 Grovelands Road Address Reading Berkshire RG1 7LP 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 939 3628 Prospects For People With Learning Disabilities Position Vacant Care Home 3 Category(ies) of Learning disability (0) registration, with number of places 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 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. Learning disability (LD). The maximum number of service users to be accommodated is 3. Date of last inspection 28th February 2007 Brief Description of the Service: Grovelands Road is a small care home that offers a service for three adults, who have varying degrees of learning disabilities. It is a domestic semidetached house in a residential area of Reading, approximately ten minutes from Reading town centre. The home has an enclosed landscaped back garden accessible from patio doors in the lounge. On the ground floor there is a small lounge, kitchen with adjoining dinette and one bedroom. On the first floor there are two bedrooms, an office/sleep/in room for staff, and bathroom. The home is on a public transport route and there are local amenities within a short walk of the home. The current scale of fees is £529.69 per week. 136 Grovelands Road DS0000011064.V357607.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 0 star. This means the people who use this service experience poor quality outcomes. This is the first inspection the Commission for Social Care Inspection (CSCI) has undertaken within the inspection year 1/04/07 to 31/03/08. The evidence obtained to inform this report include a 4-hour site visit to the service that enabled the inspector to observe care practice, and speak to the people who use the service, staff and a service manager of the organisation who is based at Prospect day care centre, and is supporting the service in the absence of a manager. The previous manager completed an Annual Quality Assurance Assessment (AQAA) December 2007, which was used to inform this report. The AQAA gave us information about the people who use the service, staff and how the home is managed. We also used information obtained from surveys’ that had been completed by relatives of people who use the service, a general practitioner and staff, and information we had received about the home over the inspection year. Documentation viewed by the inspector at the site visit was also used to inform this report. From the evidence seen by the Inspector and comments received, the Inspector considers that the home may not be able to provide a service to meet the needs of individuals who are not of a Christian faith. The service manager confirmed that Prospect would only consider meeting the needs of people of various religion if they follow the same principles of Christianity; also confirming that Prospect is a Christian organisation who do not employ staff unless they are practising Christians. The home would be able to meet the needs of people of various race, or culture, and follows the organisation’s policy and guidelines to manage issues relating to equal opportunities, diversity, and anti-oppressive practice. What the service does well: The service provides a homely and friendly environment for the people who live there. Residents say they are happy, and their independence is promoted as they are enabled to make decisions in their lives. Staff are aware of the residents’ needs and know to meet those needs. Residents’ live a full and varied lifestyle receiving support from staff within day-to-day living tasks, for example cooking and shopping, and support to day care services and evening clubs. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 6 Residents’ have an Essential Lifestyle Plan (care and support plan) that details their needs and how they want those needs to be met; the plan is designed to promote their independence, choice and decision-making. Staff know how to meet the basic needs of residents’, but only from daily records made as opposed to reference from the residents’ care and support plan. What has improved since the last inspection? 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. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 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 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may want to use the service receive information about the service and those who choose to use the service have their needs assessed prior to admission, but a review of their needs assessment is not regularly undertaken. EVIDENCE: The service users have lived in the home for many years and the home has no vacancies. Records identify that a thorough assessment of the service users’ needs had taken place prior to their admission, and demonstrate that the previous manager had written to the service users’ care managers reminding them that a review was due in 2006; those reviews took place, but no further reviews have taken place since that date; this is discussed further with the ‘Individual Needs and Choices’ section of this report. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have a plan of care, but their care and support plan is not used as a working document, and is not regularly reviewed. People who use the service are supported to make decisions within their lives and are enabled to take risks, in order that they are as independent as possible. EVIDENCE: Person centred care and support plans detail the service user’s health and social care needs and how they want to be supported in meeting those needs, but the two service user care plans viewed have not been reviewed since March and April 2006. A member of staff informed the inspector that the previous manager had commenced the process of arranging a review of the service users needs assessment/care and support plan prior to leaving December 2007, and had been informed by social services that they were too busy at that time to undertake those reviews. There was no record to support this and no record to demonstrate that the manager or staff had arranged a 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 10 review of the service users health and social needs with or without care management involvement. A member of staff reports that staff do not have anything to do with the care and support plans as the previous manager would have undertaken all reviews and updating of the plans, confirming that staff detail daily events within the service users daily records. A relative survey stated, “I haven’t been informed of any annual review meeting in 2yrs”. Risk assessments filed separate to the service users’ care and support plans clearly detail associated risks and how to minimise those risks, and these were last reviewed prior to the manager leaving post in December 2007. Daily records gave a detailed overview of how the service user is being supported by staff, and of any health/social care issues arisen on the day with action taken. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 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): 12, 13, 15, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service live a full and active life around the choices they have made, are respected by staff and enabled to keep contact with family and friends within the community. People who use the service are encouraged to enjoy a healthy diet based on the choices they have made. EVIDENCE: The staff rota identifies that one staff member is on shift between 7am and 10pm with improvements of an overlap shift since the last inspection; the overlap of shifts twice weekly is to facilitate shopping trips, escort service users to clubs/entertainment, and enable those service users who do not want to go to go out to stay at home with staff whilst the other staff member escorts the service user/s to the activity. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 12 The service users were at the day centre at the beginning of the inspection arriving home at 4:30pm, all appeared happy and full of stories about their day whilst they independently made a choice of how to spend their evening; two service users choose to sit in their room listening to their favourite music whilst another helped staff prepare the evening meal and talk to staff and the inspector about daily events. The staff member on shift was preparing to escort the service users to a club, but a service user informed her that there was no club that evening due to half-term holiday. The staff member telephoned a contact to have this confirmed. Service users spoke of visiting family and friends and of the daycentre, clubs and church they visit. The service users care plan supports the service user’s choice within social/recreational activity and keeping contact with family and friends. A relative said within a survey, “they arrange daily after care at a local day centre which has various activities, such as pottery lessons”. Relationships with families are recognised as being important and service users’ family members are encouraged to be involved in people’s lives. A relative said within a survey, “we make regular contact with X and see X most weekends and all bank holidays”. Menu plans were varied offering fresh fruit and vegetables that were observed within the home. Service users take turn to choose an evening meal and help staff to prepare the meal; records identify that if the other service users dislike the choice of meal an alternative choice is offered although the record does not identify choice made. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service receive support to meet their personal and health care needs, and are protected by the homes policy and procedure in the administration of their medication. People who use the service do not have their health care needs reviewed within the home to ensure care plans support those needs. EVIDENCE: Essential Lifestyle Plans and the completed sections of the “All About Me” files detail guidance on how service users wish their personal and healthcare needs to be supported. Daily records detail that all necessary help is given as preferred by the service user. Although the service users needs assessments and care plans have not been reviewed since 2006, there was evidence of health care appointments and outcomes entered prior to the manager leaving December 2007 Daily records maintained by staff detail health care appointments attended and support required attending those appointments. Records identify that all service users are registered with a G.P. A CSCI returned G.P comment card 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 14 states that they are able to see their patients in private, and that staff within the home demonstrate a clear understanding of the care needs of the service users’. The home uses a monitored dosage system within the administration of the service users medication. Staff confirmed that a pharmacist undertakes an annual audit/inspection of the system to ensure safe practices within the administration of medication, but there was no record to evidence that an audit had taken place. Medication records matched medication in stock and all medication was secure within a locked medication cabinet. Staff said they have received medication training and that only trained staff administer service users medication, but no records were available to evidence training attended. A GP comment card said service users medication is appropriately managed within the home. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service and their representative know who to go to if they have a concern or complaint. People who use the service are protected from abuse. EVIDENCE: The Commission for Social Care Inspection has received no formal complaints about the service provided. The home has a complaint procedure and people who use the service and their representatives feel listened to and say within surveys received that they know how to make a complaint. A relative said within a CSCI survey “If I have a complaint I would initially contact the manager of the home. At the moment the home is in the process of appointing a new manager”. The home’s Annual Quality Assurance Assessment (AQAA) completed by the previous manager in December 2007 states the service had received three complaints and all were resolved within 28 days, 2 were upheld. The staff member said that she had attended safeguarding adult training and has a National Vocational Qualification in care; the staff member was able to demonstrate the procedure to follow should an allegation of abuse be made or suspected and was able to show the inspector the home’s copy of the Local Authority Multi-agency Safeguarding Adult policy and procedure. The home’s AQAA reports that there has been no safeguarding referrals and no safeguarding investigations taken place. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service live in homely and comfortable surrounding that does not fully provide a safe, clean and hygienic environment. EVIDENCE: The home is in need of some décor to enhance the comfort of the home with particular reference to the stairs/hallways, bathroom and kitchen/dinette. Senior management have identified repair/décor required within the kitchen/dinette area and confirmed an action plan in place to bring this area up to a minimum standard. Plastering and painting of the adjoining neighbour stair wall is required as identified at the previous inspection, and the stair and hall carpet is showing signs of wear and tear with holes/rips identified in five places clearly putting the service users at risk of trips/falls. The bathroom had no blind/curtain to ensure the privacy of the service users is respected; this was addressed at the previous inspection. The sealant around 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 17 the bath is worn, broken away in areas and dirty with a risk of infection to the service users. The bathroom remains the same as reported at the previous inspection with staining in the sink and bath and rust on the radiator. The front exterior of the house was unkempt as lengthy weeds had penetrated through the gravel and an old bed had been left that had apparently been there for a number of months; this was pointed out to a service manager at the visit who instructed a member of staff to arrange the removal of the mattress and agreed the home had an unkempt appearance on entering. Household tasks were incomplete as some of the skirting boards, doors and windows were dirty. The back garden is landscaped and observed to be a nice area for the service users to enjoy in the warmer months. The service manager confirmed that staff support service users to maintain the cleanliness of the home. Agreement was reached that staff should take overall responsibility for the cleanliness of the home with support from the service user if able to promote the service users independence and participation in the management of the home. Staff say it is difficult to ensure an expectable standard of cleanliness around the home as only one staff member on shift to meet the needs of the service user, cook and clean, with the added task of more administrative tasks normally undertaken by a manager due to the vacant manager position. Staff say they have had infection control training and the home’s AQAA confirms this, but records were not available at the inspection to confirm training received. The home has infection control policies and procedures and a copy of the Department of Health guidance notes essential steps to safe, clean care. Protective clothing was available for staff to assist service users with personal care and hand washing facilities liquid soap and paper towels available to promote infection control. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team support the people who use the service, but records are not available to demonstrate training, skills and competences of the staff. Insufficient staff numbers risk continuity of care for the people who use the service. Previous recruitment practices assessed demonstrate that people who use the service are protected by the homes recruitments practices. EVIDENCE: The Annual Quality Assurance Assessment (AQAA), which is a legal document that had been completed by the previous manager December 2007, reports one staff member has an NVQ in care: the staff member confirmed at the site visit that she has an NVQ level 2 and is in the process of completing Level 3. There has been a decline in staff numbers since the last inspection 28/02/07 from 6 part time staff (3 were relief) and a manager, to 3 part time staff (2 are relief) and no manager. Extra tasks have been placed upon the permanent staff member as delegated by the service manager based at Prospect day care service, but the staff 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 19 member confirmed no extra hours have been issued to complete management tasks in the absence of a manager. The service manager reports difficulty in recruiting staff and a manager, but states continuity of care is achieved by using the same relief and agency staff within the home as used at the day care centre, which is used by the service users’. The rota identifies that 3 part time staff and agency staff cover all shifts with an overlapping shift two afternoon or evenings a week to cover activities. Staff training and recruitment files could not be viewed, as the service manager does not have access to the cabinet used by the previous manager. The organisation has been aware of this since the manager left December 2007. The last key inspection reports that recruitment procedures were followed; no staff have been recruited since that date. The AQAA, states Prospects has a robust recruitment policy and procedure and CRB checks are carried out and references obtained. The AQAA reports that staff receive mandatory training and a staff member confirmed this. The AQAA states that staff have individual personal files that detail training and courses undertaken, but no records were available to demonstrate that a staff training plan is in place. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have a manager, and staff have limited support from management within the organisation to ensure systems of operation within the home are maintained, to ensure the safety of the people who live in the home. EVIDENCE: The requirement from the previous inspection to register a manager with CSCI was met. The registered manager resigned December 2007 and the management position is vacant. A service manager within the organisation reports that they are experiencing difficulties recruiting a manager and confirmed that the service manager supports the staff team in the absence of a manager. The service manager confirmed visits made to the service are limited and that staff can contact the service manager for support at the organisations daycentre. The service users’ within the home attend the daycentre Monday to Friday 9am to 4:00pm. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 21 There is one permanent staff member, as discussed in the staffing section of this report who takes responsibility for the staff rota and other admin tasks, but basic fire safety checks have not been completed since the manager resigned. Regular regulation 26 inspections, as required within the Care Homes Regulations have not taken place and no other form of quality monitoring of the service was evident. At the site visit the service manager delegated tasks to the staff member, for example to seek quotes for the repair of flooring, and to arrange and conduct supervision of the relief staff. The staff member has no supervision or management experience to support a team, and confirmed that no other hours have been allocated to account for management responsibilities. The staff member and service manager confirmed one supervision session with the staff member had taken place since the manager left, but there was no record to evidence support received. Service users care plans and health care records are not updated as staff said they would only make recordings within the service users’ daily records sheets, as they do not have a full understanding of the care planning system used. It was evident that staff are being left to manage the service with minimum support. The management of the organisation do not visit the service regularly to ensure safe systems are in place to protect the people who use the service. Care plan and support reviews to assess the service users needs do not take place in the absence of a manager. The service Annual Quality Assurance Assessment (AQAA) completed by the previous manager states that all policies and procedures are updated. The AQAA states one area that the home could do better, as quoted, ‘Involve the whole of the staff team in better understandings of the National Minimum Standards and Care Home Regulations. A team training day on this could be planed for 2008.’ The AQAA dated December 2007 states ‘Prospects has recently introduced a management review system and a skills and knowledge framework as a way of monitoring management activities while at the same time supporting managers in their job to improve performance and quality. The home does not have a manager and the monitoring and support the service receives is limited and puts the people who use the service at risk. 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 22 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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 1 X 2 X X 2 2 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 23 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 YA2 Regulation 14 (2)(a)(b) Requirement The provider must ensure people who use the service have their assessed needs reviewed annually, and as needs change. The person using the service and their representative/s must be involved in the review to ensure changing needs are identified with a plan of care agreed by the person and/or their representative. Timescale for action 19/04/08 2 YA6 15(2)(b)(c)(d) The provider must ensure people who use the service have their personal, health and social care needs reviewed within their plan of care as drawn from their reviewed assessment of need to ensure those needs continue to be met. 13. (3) 13. (4)(a) 23. (2)(b) (d) The provider must ensure a planned programme of renewal, refurbishment and maintenance is carried out and submit those plans to CSCI: Plans to place curtains and/or DS0000011064.V357607.R01.S.doc 19/03/08 3 YA24 19/05/08 136 Grovelands Road Version 5.2 Page 24 blinds within the bathroom to respect the privacy of the people who use the service. Plans to replace or repair the bathroom fittings as they are corroded and stained Plans to replace the sealant around the bath and sink as they are broken and pose a risk of infection to the people who use the service. Plans to replace the stair carpet, as five areas of wear and tear are clearly visible and pose a risk of tripping to people who use the service. Plans to ensure the cleanliness of the home that includes doors, windows and skirting boards to ensure a safe and hygienic home for the people who use the service. 4 YA37 8 (1) The provider must make provisions to have a qualified and competent manager to manage the home to ensure the home meets the needs of the people who use the service. The provider must ensure staff files are available for inspection to evident recruitment procedures followed, staff training and supervision. 19/03/08 5 YA41 17. Schedule 4 18 19/03/08 6 YA43 26. To provider must ensure a 19/03/08 regulation 26 visit under the Care Homes Regulations takes place within the home each month so as to monitor DS0000011064.V357607.R01.S.doc Version 5.2 Page 25 136 Grovelands Road standards, identify standards not being met and action plan. A record of the visit must be kept within the home for inspection purpose and a copy must sent to the Commission for Social Care Inspection each month until otherwise notified. 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 YA6 Good Practice Recommendations The provider should ensure staff have care planning training that would enable them to meet requirement 1 and 2 within this report and ensure staff have an understanding of care planning to meet the needs of the people who use the service. The provider should ensure that the décor and furnishings of the home is of a good standard to ensure the safety and comfort of the people who use the service and repair those areas they have so far identified as requiring repair to include the plastering and redecorating of the hall, stairs and kitchen. 2 YA24 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South East The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 136 Grovelands Road DS0000011064.V357607.R01.S.doc Version 5.2 Page 27 - 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!