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Inspection on 30/08/05 for Blue Grove House

Also see our care home review for Blue Grove House for more information

This inspection was carried out on 30th August 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Prospective service users and their families do have the opportunity to visit the home to see if they like it before they move there. There is a six-week trial period once someone moves to the home which means that people can test drive the home fully before they decide if it is where they want to live. This home is due to develop a new Intermediate Care Unit in April 2006 and as far as can be assessed at this point they have considered the standards prior to setting up this unit and re aware of the different needs and necessary practice for these admissions. Every service user has been issued with a contract, which means that they have been given information about what they can expect and what is expected of them at the home. Service users` health and personal care needs are fully met by staff both in the way that they are linked into other professionals and the way that they are cared for at the home by staff. This home is safe, well maintained and comfortable. There are enough bathrooms that are decorated in a non-institutional manner. Bedrooms are large enough and all have en-suite bathrooms. Service users have personalised their rooms to their own tastes and can bring in some of their own furniture if they choose. The communal areas are bright and airy and the whole home is clean and free from unpleasant smells. The Registered Manager is fit to be in charge. She has the necessary skills, experience and training to identify and understand the needs of service users and able to manage the home to ensure that staff can meet those needs. Service users and their families said that they were very happy with this home, they had no problems generally and when they did have minor concerns they could speak to any staff and they would attempt to sort things out. One family of a service user who had been at the home for about ten days talked of their anxiety about putting their relative in a home but how relieved they now were when they had seen how well their relative was and how quickly they had settled in. Staff were described as "lovely, caring people" who never reacted badly to service users and were always polite and respectful.

What has improved since the last inspection?

This is the first inspection of this home by this inspector so it more difficult to say what has improved. Recommendations from the last inspection that have been met showed improvement in the areas of reviewing of care plans and involving the placing authorities in those reviews, policy development and some areas of health and safety.

What the care home could do better:

Although the Statement of Purpose and Service User Guide are clear and include a lot of information they do not include all information necessary for service users and their families to make a fully informed choice about where to live. The home is not able to show that service users (or their representative) have read and understood their contract if they do not ask families or advocates to sign the documents on their behalf when they are not able. Service users are not fully protected by the home`s practice with regard to storage and recording of medication and the systems in place must be followed consistently by all staff. The home cannot show that service users are in safe hands at all times because they are not meeting the targets for the required number of NVQ qualified staff in the home and these numbers must be increased as a priority. Staff are not currently trained to do their jobs. The latest training analysis has shown that there are several areas of training are needed for a number of staff. Service users` financial interests are not currently being safeguarded. There are not effective controls in place to ensure that service users are receiving all money to which they are entitled. Although staff receive ongoing informal support throughout their work they are not being appropriately supervised because these sessions are not formal or planned in advance and no records are kept. This means that service users are not benefiting from a staff team that is receiving the highest levels of support possible.The health, safety and welfare of service users are being promoted and protected by the home`s procedures and practice throughout the building.

CARE HOMES FOR OLDER PEOPLE Blue Grove House 325 Southwark Park Road London Address 3 SE16 2JN Lead Inspector Lisa Wilde Unannounced 30 August 2005, 10:00am th 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Blue Grove House Address 325 Southwark Park Road, London SE16 2JN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7394 020 7231 4284 Anchor Trust Ms Jean Adams CRH Care Home 48 Category(ies) of OP Old Age registration, with number of places Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 04th December 2004 Brief Description of the Service: Bluegrove is a newly built residential care home registered for 48 older people. It is owned and run by Anchor Trust. The home is purpose built and was opened in October 2003 to replace an ex-local authority home. Many of the service users from this home transferred to Bluegrove when it opened. Many of the staff who worked at this home and are familiar to the service users also moved to work here. The accommodation is on three floors, each with a group living unit comprising 16 bedrooms all with en-suite facilities, a kitchen, a dining area and lounge. There is a secure, rear garden for use by service users. Bluegrove is situated on bus routes and is close to a local shopping area and a range of leisure facilities. Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in August 2005. The inspector spoke with the Registered Manager, Deputy Manager, staff, service users and their families. This home is about to undergo a significant change when the new Intermediate Care Unit is set up on the top floor. This process has been planned well in advance and as far as can be assessed at this point all issues have been considered. The home and organisation must ensure that this process continues to be well managed to minimise the impact on the current service users and ensure the new service users are moved to the home safely. What the service does well: Prospective service users and their families do have the opportunity to visit the home to see if they like it before they move there. There is a six-week trial period once someone moves to the home which means that people can test drive the home fully before they decide if it is where they want to live. This home is due to develop a new Intermediate Care Unit in April 2006 and as far as can be assessed at this point they have considered the standards prior to setting up this unit and re aware of the different needs and necessary practice for these admissions. Every service user has been issued with a contract, which means that they have been given information about what they can expect and what is expected of them at the home. Service users’ health and personal care needs are fully met by staff both in the way that they are linked into other professionals and the way that they are cared for at the home by staff. This home is safe, well maintained and comfortable. There are enough bathrooms that are decorated in a non-institutional manner. Bedrooms are large enough and all have en-suite bathrooms. Service users have personalised their rooms to their own tastes and can bring in some of their own furniture if they choose. The communal areas are bright and airy and the whole home is clean and free from unpleasant smells. The Registered Manager is fit to be in charge. She has the necessary skills, experience and training to identify and understand the needs of service users and able to manage the home to ensure that staff can meet those needs. Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 6 Service users and their families said that they were very happy with this home, they had no problems generally and when they did have minor concerns they could speak to any staff and they would attempt to sort things out. One family of a service user who had been at the home for about ten days talked of their anxiety about putting their relative in a home but how relieved they now were when they had seen how well their relative was and how quickly they had settled in. Staff were described as “lovely, caring people” who never reacted badly to service users and were always polite and respectful. What has improved since the last inspection? What they could do better: Although the Statement of Purpose and Service User Guide are clear and include a lot of information they do not include all information necessary for service users and their families to make a fully informed choice about where to live. The home is not able to show that service users (or their representative) have read and understood their contract if they do not ask families or advocates to sign the documents on their behalf when they are not able. Service users are not fully protected by the home’s practice with regard to storage and recording of medication and the systems in place must be followed consistently by all staff. The home cannot show that service users are in safe hands at all times because they are not meeting the targets for the required number of NVQ qualified staff in the home and these numbers must be increased as a priority. Staff are not currently trained to do their jobs. The latest training analysis has shown that there are several areas of training are needed for a number of staff. Service users’ financial interests are not currently being safeguarded. There are not effective controls in place to ensure that service users are receiving all money to which they are entitled. Although staff receive ongoing informal support throughout their work they are not being appropriately supervised because these sessions are not formal or planned in advance and no records are kept. This means that service users are not benefiting from a staff team that is receiving the highest levels of support possible. Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 7 The health, safety and welfare of service users are being promoted and protected by the home’s procedures and practice throughout the building. 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. Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 5 & 6 Although the Statement of Purpose and Service User Guide are clear and include a lot of information they do not include all information necessary for service users and their families to make a fully informed choice about where to live. Every service user has been issued with a contract; however, the home is not able to show that service users (or their representative) have read and understood this document. Prospective service users and their families do have the opportunity to visit the home, which means that people can test drive the home fully before they decide if it is where they want to live. EVIDENCE: There had been previous recommendations to include further information in the Statement of Purpose and Service User Guide to ensure that it met the requirement of Standard 1. These recommendations had not been met but as the home is due to undergo a change over next six months these documents will have to be revised again. (See Requirement 1) Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 10 The previous recommendation with regard to the contract had been met and the document now covers all the required areas. A sample of files was checked and all files had a contract in place which had been signed by the service user or stated that the service users was not able to sign. Next of kin have not been asked to sign on behalf of the service users. (See Requirement 2) The family of one service user who moved to the home two weeks prior to the inspection said that they had come to visit the home before their mother moved there but as their mother had been in hospital they did not want to move her to the home for a trial overnight stay before she moved in. The new Referrals Procedure states that the first six weeks of a stay is a trial for both the service user and staff to decide if the placement is working out. This procedure is currently adequate but will need to be reviewed before the new Intermediate Care Unit is operational as the referral route and process may be different for those service users. (See Requirement 3) The top floor of this home is to become a high support intermediate care unit by April 2006. Sixteen places will be available and currently the service users on the top floor are gradually being moved down to the other floors as places become vacant. The organisation has written to the Commission describing their plans prior to the formal variation request being sent in. The Registered Manager stated that the standards have been considered when drawing up the plans for this new unit and there will be separate facilities, equipment, training and staff team in order that the people who are moving through the unit in a relatively short time do not disrupt the lifestyles of the people who are at this home on long term placements. This standard will be examined in detail at the next inspection when plans for the change will have progressed much further. Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8 & 9 Service users’ health and personal care needs are fully met by staff both in the way that they are linked into other professionals and the way that they are cared for at the home by staff. Service users are not fully protected by the home’s practice with regard to storage and recording of medication. EVIDENCE: Service users and their families said that staff look after them and take care of all their needs. One family said that their mother had improved significantly since she had moved from the hospital to this home two weeks ago. Staff talked about service users needs and had an awareness of how to meet those needs. The inspector examined the medication stocks and records held in the home. There were gaps in some recording of medication and the stocks of some medications counted did not tally with the records. There was a medication that was no longer in use that needed to be returned to the chemist and the wrong day’s tablet of one medication had been given. (See Requirements 4, 5 & 6) Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 15 Service users are not experiencing a lifestyle that matches their preferences with regard to daily activities. There are not enough activities taking place in the home or in the local community to make sure that service users are active, stimulated and prevented from becoming bored. Service users are supported to maintain contact with their family and friends. Visitors are encouraged and made welcome whenever they wish to come to the home. Service users receive a healthy and balanced diet with choice every day. EVIDENCE: The home organises some trips for service users and there are activities that take place in the home such as exercise classes and coffee mornings. There is an activities co-ordinator one day a week who organises the coffee mornings currently and when the new development takes place, each home in this organisation will have its own full time co-ordinator. On the day of the inspection the planned activities were not taking place because of staff sickness and the Registered Manager stated that sometimes activities do not take place. On the day of the inspection there were staff available in the afternoon for activities to take place but service users on the upper floors were not brought down to use the garden. (See Requirements 7 & 8) Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 13 Families said that they could visit the home whenever they chose and are made to feel very welcome by staff. Service users cannot access the local community regularly with staff, but can get taken out if they have families available to do so. The previous requirements made relate to this area also. There was a previous recommendation that there is consultation made with service users about food. The Registered Manager said that the previous problems with too large potatoes and badly cooked vegetables have been solved but there are ongoing issues with the food. A meeting was held with service users the week before the inspection which discussed food issues and it is also discussed regularly in residents’ meetings. The Registered Manager is going to do a survey with service users and their families and will respond to the results. Service users said that generally the food is good but there are problems making sure that everyone is happy all the time. They said that the staff would cook something else if they do not want what is on offer on any particular day. On the day of the inspection the lunch appeared wholesome and there was a choice of meat or fish. Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Service users and their families said that they feel that staff listen to what they have to say and will do their best to change anything that they do not like. The current policy and procedures around complaints is not ensuring that service users are aware of everyone they can complain to or making sure that their complaints within the home are being monitored and acted upon. Service users are not being completed protected from abuse as staff have not received training in this area and there are financial issues that are discussed under Standard 35. EVIDENCE: The Registered Manager stated that currently issues such as complaints about food and other day-to-day issues are not logged as complaints when they need to be (See Requirement 9). There is a complaints procedure that is displayed prominently in the entrance hall with leaflets for service user to complete if they wish. There is an additional system called Careline where service users can talk anonymously to a number within the Anchor Trust. The complaints procedure mentions that service users can complain to the Commission but does not give the address and telephone number and does not explain what the Commission is or that service users can complain to the Commission at any time, outside of the organisation’s procedure (See Requirement 10). The Registered Manager stated that the training needs analysis has now been done (which was seen by the inspector) but the training required has not yet been delivered to staff in some areas. Only the two managers and one senior have been on Adult Protection training with the other senior staff being identified as attending next (See Requirement 11). Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 15 The home has accessed a local advocacy service who are due to visit the home to talk to service users in the next few weeks. There is an issue regarding financial protection that is linked to this standard about protection from abuse that is discussed under Standard 35. Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24, 25 & 26 This home is safe, well maintained and comfortable. There are enough bathrooms that are decorated in a non-institutional manner. Bedrooms are large enough and all have en-suite bathrooms. Service users have personalised their rooms to their own tastes and can bring in some of their own furniture if they choose. The communal areas are bright and airy and the whole home is clean and free from unpleasant smells. EVIDENCE: Blue Grove is a purpose built building and was opened in 2003. The service users’ accommodation is on three floors and there is a lift to provide access to all levels. The home is situated near to local shops and bus routes. There is a reception and large sitting room on the ground floor. There are bedrooms, a lounge/dining area and a kitchen for the group of people living on each of the floors. There is an accessible garden with garden tables and chairs. The home employs a handyperson who deals with routine maintenance. There is a communal lounge on the ground floor that looks out onto the garden. It is used for larger functions within the home or for private meetings. Each floor is colour co-ordinated and the units on each floor have names. The Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 17 lounges and dining areas are pleasant, light and airy. There is a range of different types of seating available in the lounges. The dining areas provided tables and chairs for individuals to eat their meals in groups of four. The furnishings are of good quality and overall the communal areas are pleasant places to sit. Each service user’s room has an en-suite toilet, level access shower and wash hand basin. In addition there was a bathroom with a toilet and two other toilets on each floor close to the lounge area. Each of the bathrooms had assisted baths with hoists for easy access and meets the minimum size requirements. All service users’ rooms are wheelchair accessible. The bedroom doors have magnetic closures and close when the fire alarm is activated. There are handrails on all corridors. Toilets are fitted with grab rails. In service users’ rooms the showers are level access with plastic seats fitted. A call bell system is provided. The Inspector looked into a few bedrooms. Each was furnished and carpeted to a good standard. Service users have personalised them and they contain photographs, pictures and ornaments. The standard items of furniture are provided. Doors are fitted with locks and there is also a lockable drawer in each room. There is a laundry on the first floor and on the day of the inspection the home was clean and free from odours throughout. Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 & 30 The home cannot show that service users are in safe hands at all times because they are not meeting he targets for the required number of NVQ qualified staff in the home. Staff are not currently trained to do their jobs. The latest training analysis has shown that there are several areas training is needed for a number of staff. EVIDENCE: The home is not achieving the target of 50 of its staff holding the NVQ 2 in Care. Currently only the five senior staff are undertaking the NVQ Level 3 in Care. (See Requirement 12) The Registered Manager has recently finished a thirteen-week course on dementia and some of the senior staff are due to undertake this soon. Staff have recently been undertaking Back Care training. As already mentioned, the training needs analysis was examined and it showed that there are several areas where training is needed for the staff team both in terms of the statutory training such as First Aid, Fire Training, Food Hygiene and Health and Safety and then additional areas related more specifically to the needs of the service user group (See Requirements 13 & 14). Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 34, 35, 36 & 38 The Registered Manager is fit to be in charge. She has the necessary skills, experience and training to identify and understand the needs of service users and able to manage the home to ensure that staff can meet those needs. Service users’ financial interests are not currently being fully safeguarded. Although staff receive ongoing informal support throughout their work they are not being appropriately supervised because these sessions are not formal or planned in advance and no records are kept. This means that service users are not benefiting from a staff team that is receiving the highest levels of support possible. The health, safety and welfare of service users are being promoted and protected by the home’s procedures and practice throughout the building. EVIDENCE: Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 20 The Registered Manager aims to complete the Registered Managers Award NVQ Level 4 by October of this year. She was not aware that following this she will need to undertake the NVQ Level 4 in Care. There had been a previous recommendation that a Business and Financial plan be sent to the Commission. The Registered Manager stated that this has not been competed yet but she is undertaking the work as part of her NVQ programme. This work will have to be revised again because of the imminent development. All the places at the home are block-purchased by Southwark and so the home does not have problems with securing finances for the home (See Requirement 15). The home can only keep £500 of service users’ money in the safe so cannot hold all the service users’ money in the home. They use a pooled corporate account that is only used for service users’ money. Records are kept at the home of money that is brought in for service users and what they take out. Receipts are kept for all entries. This system is acceptable if the organisation has been deemed a Corporate Appointee by the Department of Works and Pensions i.e. because the service user does not have capacity to manage their own finances. The Registered Manager was not sure if this account earns interest (See Requirements 16 & 17). Records are kept of money that is brought into the home by relatives for the service users. There is currently no record kept of the service users’ money that is due to them from benefits that are collected on their behalf by their family members. This means that staff cannot check if service users are receiving the money they are entitled to from their families. The inspector looked at a few records for service users with the Registered Manager and found varying levels of discrepancy in the money that service users’ should be receiving with one example of a family who had not brought any money to the service for their relative for a significant period of time, when they were supposed to be receiving the personal weekly allowance of £18.10. (See Requirements 18, 19 & 20) There was a previous recommendation made that staff receive supervision at least six times a year. The Registered Manager said that they are continuing to attempt to formalise the system of supervision. She felt that supervision occurs on an informal basis all the time but is not recorded as such. (See Requirement 21) On the tour of the building there were no health and safety issues noted. The required checks and tests are taking place but the Electrical System testing certificate could not be found and this was a recommendation from the last inspection. (This was found and forwarded to the Commission by the drafting of this final report) The Registered Manager stated that she would send this through to the Commission before the final draft of the report was sent out. Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 x x 2 3 HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 x 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 x x 2 2 2 x 3 Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 22 NO 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 OP1 Regulation 4&5 Requirement The Registered Manager should ensure that the Statement of Purpose and Service User Guide are reviewed to include the imminent changes to the service and all the information listed in Standard 1 is included in the service users guide. The Registered Manager must ensure that families or advocates are approached to sign the contracts on service users behalf if they are unable to sign themselves and if there is no one to sign then this must be stated on the contract The Registered Manager must ensure that the Referrals Policy and Procedure is revised to include the processes for the Intermediate Care Unit The Registered Manager must ensure that all medication is signed for at the point of administration. The Registered Manager must ensure that the stock checking sytsems at the home are in operation and are effective The Registered Manager must ensure that all systems in place Timescale for action 31/12/05 2. YA2 12 (2) 31/12/05 3. YA5 18 (1) (c) (i) 31/12/05 4. YA9 13 (2) 14/09/05 5. YA9 13 (2) 14/09/05 6. YA9 13 (2) 14/09/05 Page 23 Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 7. YA12 16 (2) (m) & (n) 8. YA12 16 (2) (m) & (n ) 12 (1) (a) 9. YA16 22 10. YA16 22 11. YA18 & YA30 YA28 18 (1) (c) (i) 18 (1) (a) & 18 (1) (c) (i) 12. to ensure that medication is stored, administered and recorded effectively are used consistently by all staff. The Registered Manager must ensure that service users are consulted about their preferences with regard to activities in and outside of the home and that the results of that survey are acted upon. The Registered Manager must ensure that activities are on offer for all service users that are appropriate to their needs and wishes and that these activities take place as planned. A record must be kept in service users files of their activity programme in order for keyworkers to assess and review with service users their levels of satisfaction with their activity programme. The Registered Manager must ensure that all complaints, including day-to-day informal complaints are recorded in the complaints book and include a record of how they were addressed and whether the service user was satisfied with the outcome. The Registered Manager must ensure that the Complaints Procedure and leaflets include the contact details of the local Commission office along with a brief explantion of who the Commission is and why service users may want to complain to them. The Registered Individuals must ensure that all staff attend appropriate Adult Protection training. The Registered Individual must ensure that at least 50 of the staff at the home have achieved 31/10/05 31/10/05 31/10/05 30/11/05 31/03/05 31/03/05 Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 24 13. YA30 18 (1) (c) (i) 14. YA30 18 (1) (c) (i) 25 (2) (c) 15. OP34 16. OP35 20 (1) 17. OP35 13 (6) & 20 (1) 18. OP35 13 (6) 19. OP35 13 (6) the NVQ Level 2 in Care (or given the current low numbers of staff with the qualification, must ensure that staff have begun the course) The Registered Manager must ensure that a Training and Development programme is drawn up for all staff that identifies the training (including dates of that training) they are to undertake to meet the needs of the service and the service users. The Registered Individuals must ensure that all staff are fully trained to meet the needs of the service users. The Registered Individuals must ensure that a Business, Financial and Development Plan is drawn up that includes an assessment of the impact of the new Intermediate Care Unit and that is then reviewed annually. The Registered Manager must establish for which service users the organisation has been deemed a Corporate Appointee. The Registered Manager must establish if interest is being earned on service users money placed in the corporate account and if it is, there must be a system in operation for fairly allocating that interest to the service users. The Registered Manager must ensure that records held of service users finances include a record of money that is expected to be brought in from families that is managed by them on service users behalf i.e. the weekly personal allowance and any other benefit entitlements. The Registered Manager must ensure that she regularly 31/10/05 31/06/05 31/03/05 31/12/05 31/12/05 30/09/05 30/09/05 Page 25 Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 20. OP35 13 (6) & 15 (2) (b) 21. OP36 18 (2) monitors the accounts of service users money to ensure that money that is due to them is being brought in by their families. If any discrepancies are noted this must be addressed with the family and service users social worker or solicitors and advocates must be allocated to service users to ensure they are receiving all money to which they are entitled. The Registered Manager must organise an urgent financial review with the social worker of the service user who has not recieved any money from their benefits for a significant period of time (and for any other service users who are in similar positions). The Registered Manager must ensure that staff receive regular formal supervsion, from someone appropriately skilled and trained to offer supervision, that meet the requirements of the standards and that records of these supervisions are kept. 30/09/05 31/12/05 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 Good Practice Recommendations Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ground Floor 46 Loman Street Southwark SE1 OEH 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. Extracts may not be used or reproduced without the express permission of CSCI Blue Grove House G52-G02 S52129 BlueGrove V225831 300805 Stage4.doc Version 1.30 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. 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