Inspection on 05/06/07 for 4 Granville Road

This inspection was carried out on 5th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 Granville Road 14/04/09

4 Granville Road 28/04/08

4 Granville Road 16/10/07

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 08/07/2008.

CARE HOME ADULTS 18-65 4 Granville Road Reading Berkshire RG30 3QD Lead Inspector Jill Chapman Unannounced Inspection 5th June 2007 10:20 4 Granville Road DS0000011054.V338987.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 4 Granville Road DS0000011054.V338987.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. 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 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 Paramount Housing Association Limited Ms Denise Williams Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (9) 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service users to be admitted over the age of 65 years. Date of last inspection 13th December 2006 Brief Description of the Service: 4, Granville Road is a care home providing personal care and accommodation for nine adults with mental disorders, excluding learning disability or dementia, two of whom are over sixty-five years of age. The home is owned by Paramount Housing Association Ltd. and is located on the edge of an estate approximately two miles from Reading city centre. All the service users have their own rooms. The aims and objectives of the home is to provide a secure and comfortable home; encourage and support residents to make decisions and choices in their lives; support and assist service users to make and maintain satisfying relationships; assist service users to develop their skills; and enable service users to engage in valued day time occupation and use of community facilities. The fees are £595 per week. 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10:20am and was in the service for 5 ½ hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector spoke with the deputy manager and staff on duty. A tour of the building was carried out and records relating to care, staffing and health and safety were sampled. A number of service users were in the home during the visit and some were willing to give their views of life in the home. The inspector spoke to the manager of the home on the telephone, when she returned from leave, to clarify some issues from the visit. Surveys were sent to the service users prior to the inspection and staff confirmed that some service users filled these in. The Commission did not receive these and so this information is not included in this report. What the service does well: Service users and others are given information about the home to help them decide if it is suitable. New service users are fully assessed to make sure the service can meet their needs. Service users are involved in their care planning and reviews and feel that they are listened to and treated as individuals. Staff respect Service users choice but some choice is restricted for safety reasons. Staff help service users have a meaningful and stimulating lifestyle. Service users are supported to eat healthily at specified mealtimes. Service users receive good support with their mental health needs and are supported to take their medication and to access health care. Service users know who to talk to if they have a concern. Staff are trained to know how to protect service users from potential abuse. 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 6 Staff on duty presented as competent and caring. Service users were positive about the support they get from staff. Recruitment procedures include checks to make sure that staff are suitable to work with vulnerable service users. Staff are trained in Equality and Diversity. A trained and experienced manager is in charge of the home. The home seeks the views of service users to help develop the service. 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. 4 Granville Road DS0000011054.V338987.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 4 Granville Road DS0000011054.V338987.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&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and others are given information about the home to help them decide if it is suitable. New service users are fully assessed to make sure the service can meet their needs. EVIDENCE: There is an up to date Statement of Purpose and Service Users Guide in place. These documents give detailed information about the service offered. The Statement of Purpose states that the home offers a service to people with enduring or chronic mental health needs. The Statement of Purpose also acknowledges that the home, with additional help from the home care service, continues to care for long-term service users with deteriorating physical needs. It states clearly that it would not admit new service users with these needs. Files sampled show that service users have a full Care Management Assessment and an assessment by Paramount Housing Association. The assessments cover the relevant areas of need, including equality and diversity and can highlight any cultural or religious needs. There is evidence of ongoing assessment of needs in multi-disciplinary reviews and service users confirmed their attendance at these. 4 Granville Road DS0000011054.V338987.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 & 9 Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. Service users are involved in their care planning and reviews and feel that they are listened to and treated as individuals. Staff respect Service users choice but some choice is restricted for safety reasons. Risk assessments help staff know what to do to keep service users safe but they need further development. EVIDENCE: There are care plans in place for service users and these are reviewed monthly. The inspector was told that there are plans to re-write these. Service users confirmed that they take part in regular Care Programme Approach reviews every six months to discuss their mental health and support needs. Copies of these were seen on files sampled. One service user was assessed in 2002 as not being suitably placed in the home as the home was not able to meet the persons deteriorating physical 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 10 needs and a suitable alternative placement has not yet been found. The inspector was told that home is currently unable to meet the personal care needs of three individuals. The Community Mental Health team has arranged for a home care service to provide additional support. (See standard 18). Service users spoken with said they were happy with the support given to them by the home staff and the home care service. Service users spoken to confirmed that they make choices in their daily lives. They also said they are given the choice of whether to be involved in their monthly evaluations. Some have signed a document saying that they don’t want to be involved in this process. Staff are confident that they listen to service users views and treat them as individuals and observation of practice supports this. Some restrictive practice, for example the locking of fridges and freezers in between mealtimes are not supported by care plans and risk assessments that are subject to regular review. Service users risk assessments need further development and updating. Risk assessments were seen on service users files sampled and these were dated 2003. In discussion with staff it was found that some risks to individuals are not documented, for example the risk of falling, the risk of wandering out of the building at night and the risk of not having an adequate diet. 4 Granville Road DS0000011054.V338987.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, 14, 15 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff help service users have a meaningful and stimulating lifestyle. Service users are supported to eat healthily at specified mealtimes but better monitoring of one service users diet is needed. EVIDENCE: Service users are encouraged to participate in activities in the local community, some can access these by themselves and others need staff support due to their mental health issues or mobility problems. Four service users attend a local resource centre a few times a week that provides activities such as cooking, computer skills, arts and crafts, and video days. Regular reviews are held with service users community mental health nurses to look at developmental and occupational opportunities. Service users said they enjoy going to the resource centre. 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 12 Staff support some service users to go to a dinner dance at a local hotel and to see shows and pop concerts. One service user has recently been to see Diana Ross and was very enthusiastic about the show. Currently the home has the use of a car to enable the less mobile service users to go out but staff are not certain this resource will be available in the future. An assessment of the transport needs of the less able service users should be carried out by an Occupational Therapist so that the home can access them appropriate resources for the future. All service users have free bus passes and most service users can access public transport with these. One service user said she uses the Readibus service to go to the resource centre. A service user confirmed that staff would support service users to attend cultural or religious activities of their choice and the home is well situated for these resources. The home has a budget to enable annual holidays and outings. Four service users are planning a holiday at Butlins this year. Managers said that being fully staffed has made a big difference in helping service users access the community and that new staff are very good at supporting service users to go out and socialise. Staff described how they support service users to keep in touch with families and friends. Some keep in touch through visits or by telephone. Some service users stay with their families and others are taken by staff to visit. Service users confirmed that staff treat them with respect and maintain their privacy. It was seen that staff relate positively to service users and maintain this positive approach when service users mental health affects their mood and how they speak or react adversely to staff. There are set mealtimes when food is available for service users. They help themselves from a selection at breakfast and lunch and staff cook a main meal in the evening. In between mealtimes the fridges and freezers are locked. This is specified in the Statement of Purpose and Service Users Guide. (see Standard 7) There are drinks available all of the time and a very large bowl of fresh fruit in the dining room. Menus show that a variety of nutritious meals are provided and service users said they could have alternatives. Service users spoken with were happy with the food provided. 4 Granville Road DS0000011054.V338987.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): 18, 19 & 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users receive good support with their mental health needs but the home does not meet the personal care needs of some service users. Service users are supported to take their medication and to access health care, but improvements to medication safety are still needed. EVIDENCE: The home does not offer personal care to service users. Managers said that they have been told by the organisation that they are not registered to carry out the personal care tasks the service users require. The service users concerned do not have nursing needs and support staff could give this care. The homes registration does cover personal care and the required tasks fall into this category. Currently home care support has been arranged by the community team to meet the service users needs. There are separate care plans for home care staff and the home carers report to the care manager who has purchased the service. The home carers do not record specifically what care has been given, but write mostly write ‘all care given’ on their record. This makes it difficult for mangers to monitor that the service users care needs are being met. 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 14 Paramount staff said that they need improved communication between the home carers and themselves to provide continuity of care to the service users. Some service users need help at times when the home care staff are not available. At times there is only one staff on duty and at night the staff is sleeping in, which limits the opportunity for personal care to be carried out. The inspector was told by staff that there have been occasions when the usual home carers are off duty and service users have not been happy to allow a stranger to shower them, after refusing the carer they then ask Paramount staff to do this. If the home continues to accommodate service users who have physical care needs it should review its policy of not offering personal care to service users. Service users spoken with are pleased with how Paramount staff help them, one said ‘I don’t know how I would manage to take care of myself and my room’. A previous requirement ‘to monitor service users daily health has been met’. Weight charts are now kept and health records are better organised and more accessible. Records sampled showed evidence of service users contact with health professionals. A requirement ‘to review the medication system to ensure its safety’ has not been met. Staff are still dispensing medication from the labelled blister packs into pots before giving it to the service users. Medication should be given straight from the pharmacy labelled container to reduce the risk of error. Staff should only sign the record when the medication is administered to the service user. The pharmacy provides staff with training and has carried out a visit to the home since the last inspection. Staff competency is reviewed regularly but this is not recorded so cannot be evidenced. 4 Granville Road DS0000011054.V338987.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know who to talk to if they have a concern. Staff are trained to know how to protect service users from potential abuse. EVIDENCE: The Commission has not received any information about complaints against the service made by service users or their relatives. Staff confirmed that they receive training on how to deal with service users complaints in their induction period. No complaints have been received by the home and service users spoken with said they would know who to talk to if they had a concern. A copy of the Complaints procedure is displayed on the notice board. The recruitment process carries out Criminal Records Bureau and Protection of Vulnerable adults list checks. There have been no safeguarding adult referrals since the last inspection. The manager has received POVA training as part of her NVQ Registered Managers Award. Staff spoken with had received POVA training. New staff are due to do this. 4 Granville Road DS0000011054.V338987.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, 27 & 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The premises are in need of redecorating and upgrading. The premises do not meet the diverse needs of all of the service users. Some health and safety issues need to be addressed to make the premises safe for service users. EVIDENCE: The home is kept clean and as homely as possible, a cleaner/rehabilitation worker is employed part time from Monday to Friday. Service users were complimentary about this staff members support. The large garden is well kept; a gardener is employed every two weeks. The building is shabby and in need of internal redecoration and some of the communal carpeting is stained. Some replacement windows have been installed but the majority are metal-framed windows that are single glazed and have no security locks. 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 17 There are a number of issues about the premises that show that it is in need of refurbishment and adaptation/extension to meet the needs of the current service user group. The home is intended to be a home for life but the building is not suitable for some service users who have increased physical needs. The needs of three service users with physical needs and one who has dementia are difficult to meet in the current environment. A requirement to review the bathing and toilet facilities has been met. Occupational therapist assessments for the three service users who have mobility problems show that the current bath and shower rooms do not meet their needs. Paramount Housing informed the Commission that they met with the landlords Reading Borough Council in February 2007, to discuss options for improving the building. The Commission has received no further updates on this situation. The bathrooms and toilets have been identified as not fit for purpose for some service users by the Occupational Therapist, Environmental Health Officer and the home care service will not shower the service users concerned for the same reason. The Environmental Health Officer has visited and identified a number of issues that need addressing. These include the steep gradient of thee pathways from the road to the front door is not safe for wheelchair access and is a slip hazard. Non-slip flooring is needed in the ground floor corridor to some bedrooms. Doors are not wide enough for wheelchair users. There was no evidence of the home having an infection control policy or staff having training on infection control. The home staff and home carers currently deal with incontinence linen. The washing machine does not have a sluice/disinfection facility and consideration should be given to purchasing one that has this facility. 4 Granville Road DS0000011054.V338987.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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels need review to meet the current needs of the service users. Staff training needs to be updated and reviewed to meet the needs of the service users. Recruitment procedures include checks to make sure that staff are suitable to work with vulnerable service users. EVIDENCE: The staff team is now fully recruited and managers were positive about the capabilities and attitude of the newly recruited staff. Staff on duty presented as competent and caring. Service users were positive about the support they get from staff. Managers said that staff morale has improved now that the staff team is complete. They said they still feel a lack of direction from the organisation as to how to meet the diverse needs of the service users who do not fit the homes criteria and are currently living in an in an unsuitable environment. It was clear from discussion with staff that they are willing to be flexible in their way of working to meet service users diverse needs and help them continue to live in the home of their choice. 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 19 It was highlighted in the previous inspection report that the staffing establishment has not been reviewed since the home was set up as a rehabilitation unit for fairly independent service users. A previous requirement ‘to review the function of the home so that staffing ratios and service users suitability for the home can be assessed’ has not yet been met. There is further evidence on this inspection that this needs to be carried out. Nighttime staffing needs to be reviewed because several of the service users are routinely up and about during the night. There have been two service user falls recorded during the night and one service user with dementia went missing at night and this was not noticed by the sleep in staff until the next morning. The manager said this issue has been raised with senior managers. Individual Risk assessments should be carried out to identify the waking night needs of the service users and the relevant resources put in place. It was seen that staff deployment during the day varies according to need but that at times there will be only one staff on shift. Staff say it is difficult to meet unexpected personal care needs at these times. A requirement to keep the required staffed recruitment documents on site has been carried out. Managers confirmed this but they could not be seen because the home manager was not on duty that day. A newly appointed staff confirmed the recruitment process carried out and that references and Criminal Records Bureau and Protection of Vulnerable Adults list checks had been carried out. The recruitment procedure includes an Equality and Diversity questionnaire. New staff confirmed that they have a 6 week induction to the home and that they have received Equality and Diversity training. A previous requirement to ensure that staff training is updated has not been carried out. Staff confirmed that they are still waiting for updates on core training. There is no evidence of core mental health training being routinely provided for staff. The manager said that this used to be provided by a local health resource but this is no longer available. Managers said that new staff are in need of mental health training. This should include a basic knowledge of mental health and training regarding the specific type of illnesses that affects the service users in the home. Managers said that all staff are in need of refresher training on Obsessive Compulsive Disorder and Dementia training to meet current needs. The home needs to develop its programme of National Vocational Qualification training. Currently only the manager has an NVQ. 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 20 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 21 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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A trained and experienced manager is in charge of the home. Senior managers carry out monitoring visits to the home but the evidence is not kept in the home. The management of the service is compromised by a lack of clarity of the function and purpose of the home and accommodation that is unsuitable to meet the needs of some service users. Some health and safety deficits put service users at potential risk. The home seeks the views of service users to help develop the service. EVIDENCE: The manager has National Vocational Training Qualification level 4 and the Registered Managers Award. She has worked in the home for over 10 years. 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 22 There are a number of unmet requirements from the previous inspection and the role and function of the home is still unclear due to the deteriorating needs of some service users. Plans to bring the building up to standard are not yet finalised and other professionals have deemed the bathroom facilities unfit to meet the needs of some service users. Health and safety records were sampled and some are well maintained and some equipment is regularly serviced. Monthly health and safety audits are carried out and defects reported to the maintenance department. Accident and incident records are regularly audited and routine checks are made to fire equipment. A security on-call system is in place. There are some health and safety shortfalls that have not been addressed. Hot water temperatures from outlets accessed by service users have been recorded as over 50 degrees for a period of 7 weeks and no action has been taken to rectify this. This was subject to an immediate requirement because this poses a potential risk of scalding to service users. Advice should be sought from the Environmental Health Officer as to the best way to regulate hot water temperatures in the home. Staff said they couldn’t open bedroom door locks in an emergency. The deputy said she had to climb through a service users bedroom window to gain access on the inspection day. The inspector was later informed that access can be gained but staff were not aware of which keys to use. The Environmental Health Officer has identified a number of health and safety issues that need action. (See Standard 24) An in house quality assurance check is carried out monthly and action plans developed. Tenant satisfaction surveys and service users quality assessments are carried out. Regulation 26 visits are carried out monthly but copies were not available in the home to be inspected. 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 23 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 1 28 X 29 1 30 1 STAFFING Standard No Score 31 X 32 1 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 2 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 3 1 X 2 X 3 X X 1 X 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 24 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. Standard YA18 Regulation 14.1(d) Requirement To accommodate only those service users whose needs it is able to meet. Unmet timescale 01/03/07 To review the medication administration system to ensure its’ safety. Unmet timescale 01/02/07 To ensure staff training is updated. Unmet timescale 01/04/07 To review the function of the home so that staffing ratios and service users suitability for placement in the home can be assessed. Unmet timescale 01/04/07 Individual Risk assessments should be carried out to identify the waking night needs of the service users and the necessary resources put in place. All staff working in the home should have training to meet the mental health needs of the service users, to include a basic knowledge of mental health and training regarding the specific DS0000011054.V338987.R01.S.doc Timescale for action 01/08/07 2. YA20 13.2 01/08/07 4. 5. YA35 YA37 18.1 4.1 01/08/07 01/08/07 6. YA9 13(4) 01/08/07 7 YA35 18 ©1 01/08/07 4 Granville Road Version 5.2 Page 25 8 YA42 13(4) type of illnesses that affect the service users in the home. Ensure that hot water is regulated to control the risk of Legionella and the temperatures of hot water from outlets accessible to service users is delivered at a safe temperature to reduce the risk of scalding (43 C) Advice should be sought from the Environmental Health Officer as to the best way to regulate hot water temperatures in the home. 30/06/07 9 10 11 YA42 YA9 YA37 13(4) 13 (4) 26 Ensure that all staff know how to gain access to service users bedrooms in an emergency. Individual risk assessments need further development. Copies of regulation 26 reports should be available in the home to be inspected. 30/06/07 01/07/07 01/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA35 YA30 YA13 Good Practice Recommendations The home needs to develop its programme of National Vocational Qualification training. The washing machine does not have a sluice facility consideration should be given to purchasing one that has this facility. An assessment of the transport needs of the less able service users should be carried out by an Occupational Therapist so that the home can help access them appropriate resources for the future. If the home continues to accommodate service users who have physical care needs it should review its policy of not DS0000011054.V338987.R01.S.doc Version 5.2 Page 26 4 YA18 4 Granville Road offering personal care to service users. 5 YA30 The washing machine does not have a sluice/disinfection facility and consideration should be given to purchasing one that has this facility. The need for restrictive practice should be evidenced by care plans and risk assessments. 6 YA7 4 Granville Road DS0000011054.V338987.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. 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