Inspection on 25/01/06 for 136 Grovelands Road

This inspection was carried out on 25th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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 7 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 19/02/08

136 Grovelands Road 28/02/07

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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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 Kerry Kingston Unannounced Inspection 25th January 2006 10:00 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 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.V276641.R01.S.doc Version 5.1 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.V276641.R01.S.doc Version 5.1 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 Mrs Faith Gardner Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th September 2005 Brief Description of the Service: Grovelands Road is a small Care Home that offers a service for three adults, of both sexes, who have varying degrees of learning disabilities. It is a domestic house in a residential part of Reading approximately ten minutes from Reading Town Centre. The home has one ground floor and two first floor bedrooms, a small sitting room, dining room and kitchen. The home is on a public transport route and there are local amenities within a short walk of the home. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place on the 25th of January. 2006. Two residents were in the house for a short time but the inspection focussed mainly on records and some concerns raised by the family of one of the residents. The manager was available throughout the inspection process. What the service does well: What has improved since the last inspection? What they could do better: The home could make sure that residents are able to go out, if they want to at weekends. Staff must make sure that residents are helped to look after their health properly. Any complaints about the home could be recorded in the complaints book. The provider could look at the way it uses residents mobility allowance. Parts of the home could be decorated to make it look nice. The manager could make sure she sees all staff records to check staff are safe and able to work in the home. The home could have a way of making sure they can check that they are offering good care to the residents. Staff could be trained to make sure they know all about health and safety. Please contact the provider for advice of actions taken in response to this 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 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.V276641.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 All service users have a contract/statement of terms and conditions. EVIDENCE: The service users have been provided with a statement of terms and conditions, which they and the home manager have signed. There are a few minor omissions, which were discussed with the home manager (identifying the residents’ room and who pays the fees.) The contracts have been signed by the service users after they were explained to them by the manager, who has also signed them. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were assessed at this inspection. EVIDENCE: 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 Service users opportunities to take part in community activities at weekends are, currently, limited. EVIDENCE: The home has a very small staff team that results in there often being only one person working at any one time. Some service users need one to one support to access activities external to the home and the opportunities for this have been limited (at weekends). A service users family have noted this issue as a concern. The records showed that one service user had been to the church service on Sundays but otherwise had been out only twice in the month, in the evenings or at weekends. The manager explained that there had been more activities but the service user sometimes refused to participate, there were no records to evidence this. The manager has now reviewed the staffing levels, particularly at weekends and an extra twenty hours per week has been made available. There will be extra staffing at weekends to enable residents to participate in community activities on a more regular basis. Residents do attend day centres five days per week. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 11 Records of activities also need to be kept to service users making choices and declining to participate in particular activities. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Service users are well supported with their personal care needs and medication is administered safely. Service users health needs are not effectively met. EVIDENCE: Individual care plans detail how service users are to be supported and there is evidence on the daily records that all necessary help is given as preferred by the service user. There is limited medication given, the home has a robust medication administration policy and the records were accurate. A pharmacist visits the home on a three monthly basis to check administration procedures and no problems were noted on the last pharmacists report. Service users are supported to make necessary health appointments but there were two incidents of these not being followed up. Results are not sought from the G.P surgery as the home waits for the surgery to contact them. This was discussed as not good practice as it is not informative or protective and serious issues could get overlooked. One appointment for a potentially serious health condition, which took place in August 05, recorded as needing following up has not been concluded. A resident’s family have noted this as a concern on several occasions. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a complaints policy and procedure but complaints received directly by the provider are not recorded in the home. Service users are, generally, safeguarded for abuse. EVIDENCE: The home has a complaints policy and procedure and record all complaints in the complaints book. However there is concern that complaints received by the providers, directly, are not passed back to the home. One complaint, which was copied to the C.S.C.I, has not been entered in the complaints book and the present manager had no knowledge of it. The manager is discussing this issue with her senior managers. The home has a vulnerable adults procedure and the manager had a good understanding of how to keep the service users safe. She has worked hard to ensure that service users monies are well kept. Bank records are now available and service users have been provided with receipts for care bills and any other large expenditure. The provider charges the service users their mobility allowance for transport, this does not always correspond with their monthly transport costs. This practice needs to be reviewed urgently. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The home has high standards of cleanliness and hygiene but there is areas of the home that are looking rather ‘tired’ and ‘shabby’. EVIDENCE: The home is well kept with good quality furniture and fittings, it is very comfortable and homely. There are areas of the home that are beginning to look shabby and are in need of decoration, this will assist staff to keep up the high standards of cleanliness. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 This is a very small staff team but it appears to be competent and is qualified. An increase in permanent hours will assist the team to be more effective. The home has a robust recruitment process but some of the safety evidence is not in the home. Staff are supervised on a regular basis. EVIDENCE: The staff team, currently, consists of the manager and one full time staff member. There has recently been a staff review and the homes fulltime, permanent equivalent will be raised to 3.57. This will enable the manager to ensure that there are times when there are two staff on duty to support those service users who need one to one support to access the community, particularly at weekends. The shift patterns have also been reviewed and the changes made should result in more availability of staff at appropriate times. The current staff are both N.V.Q.2 or above and have a good knowledge of the service users needs. The home does not keep some of the necessary staff information and the manager has not seen C.R.B. or medical checks for some staff she is to rectify this omission. The manager supervises the staff member four to six weekly, they have an annual appraisal and regular staff meetings, which include bank staff are held. The Services Manager manages the home in the prolonged absence of the manager. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 16 The home and staff have a training plan but this could be more clear about the training planned and that completed. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 The home does not have a quality assurance system. The home appears to be safe but the mandatory Health and Safety Training is not up to date. EVIDENCE: The home does not have a formal quality assurance system but regular regulation 26 visits are now competed. There were no records of the mandatory Health and Safety training courses. The fire officers’ recommendations have been complied with and there were risk assessments for some radiators. The manger was advised that these needed to be more specific and detailed. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 18 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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 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 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 2 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X X X 2 X X 2 X 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 19 YES Are there any outstanding requirements from the last inspection? 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 2. 3 4 5 6. 7. Standard YA13 YA19 YA22 YA23 YA34 YA39 YA42 Regulation 16.2(m) 13.1(b) 17.2 (schedule 4.11) 13.6 19.4 24 13.4 Requirement To ensure that service users are able to participate in appropriate social, community activities. To ensure service users healthcare needs are met. To keep a record of all complaints received within the home. To review the system of how service users pay transport costs. To ensure all necessary staff records are verified by the manager. To develop a quality assurance system. (1/12/05) To produce more detailed risk assessments for safe working practices and radiators. To evidence that staff have mandatory Health and Safety training. (Repeated requirement x3 01.10.04) Timescale for action 01/03/06 01/02/06 01/02/06 01/04/06 01/03/06 01/04/06 01/03/06 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 20 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 YA24 Good Practice Recommendations To redecorate, as necessary. 136 Grovelands Road DS0000011064.V276641.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 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. 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