Inspection on 19/05/05 for Graceland Care Home

This inspection was carried out on 19th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 but made no statutory requirements on the home.

Other inspections for this house

Graceland Care Home 28/06/07

Graceland Care Home 24/04/06

Graceland Care Home 05/10/05

Graceland Care Home 24/01/05

Graceland Care Home 30/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Graceland Care Home 113a Parchmore Road Thornton Heath Croydon CR7 8LZ Lead Inspector Mohammad Peerbux Unannounced Inspection 19 May 2005 9:30am 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Graceland Care Home Address 113a Parchmore Road, Thornton Heath, Croydon, Surrey, CR7 8LZ 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 8771 5691 020 8768 1445 Graceland Care Home Limited Mrs Grace Basoah Care Home 2 Category(ies) of Learning Disability (2) registration, with number of places Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 24 January 2005 Brief Description of the Service: Graceland is registered as a care home to provide a service for up to two young adults between the ages of 18 to 65 years, under the category of learning disabilities. There are two Registered Providers, one of whom manages the home on a day-to-day basis. The home is positioned on a main road in Thornton Heath, with the town centre and local transport links within easy reach. Due to the good location, service users benefit from being able to access a variety of community resources. The home comprises of a lounge/ dining area, small kitchen, two large bedrooms, one smaller bedroom, upstairs bathroom/ toilet and ground floor toilet/ shower room, with laundry facilities outside. Entry to the premises is via the rear of the building as the proprietors’ business office is at the front. There is no garden but a good- sized paved yard for service users to utilize in the summer months. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 09.30 am and took place over 4 and half hours. The service users were out but one came back during the course of the inspection. This enabled the service user to meet with the inspector during the inspection. During this inspection the manager and owner were both interviewed. Records, policies and care plans, and the building were examined, as were the service users’ bedrooms. What the service does well: What has improved since the last inspection? The manager has included house rules on smoking, alcohol and drugs in the Service Users Guide. Service user plans are now being reviewed more regularly. The home has a new induction pack in place for new staff. The manager has attended the training in adult protection. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 6 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. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 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 standard(s) 1,2,3,4 and 5 The Statement of Purpose and Service User Guide are inadequate and does not provide sufficient information for prospective service users to be clear about the services the home provides to meet their needs. The home is able to demonstrate that service users needs are being properly assessed, and that the range of needs presented is being appropriately met. EVIDENCE: The Statement of Purpose clearly defines the aims and objectives of the home and sets out the detailed principles and philosophy of practice. However it did not include all information as per regulation 4. The Service Users Guide was found to be well written but again did not contain all information as per regulation 5.The manager needs to amend both documents. Service users are admitted to the home after the home and the placing authority have carried out a full assessment of their needs. The prospective service user is also involved in the process. This covers all aspects of the person’s life, including strengths, social and cultural needs and psychological needs. The home then develops its own care plans from these assessments and formal reviews of each service user. The service users are in regular contact with their General Practitioners and other community based health care professionals who visit the home and check that assessed needs are being met. No service users have moved to the home since the last inspection. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 9 It was evident that both service users are benefiting from living in a small family style home and are involved in the day to day running. The service users in this home have mild to moderate degrees of learning disabilities and therefore relatively higher levels of independence. They have many skills including social and practical skills and are able to freely access the facilities without restriction. The home’s admission policy identifies the criteria for admission as well as details about introductory visits and opportunities to try out the service. The two service users each have a contract, known as “individual placement agreement” and provided by the local authority, LB of Croydon, that states the terms and conditions of occupancy at Graceland. The document gives clear reference to the room to be occupied, as well as the weekly fee. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 10 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 standard(s) 6,7,8,9 and 10 Service user’s care plans are comprehensive and include detailed information about their needs and personal goals. This will help staff know the service users’ needs and how to meet them. Service users are involved in decision making about their lives, they participate and can take some risks so that they live as normal a life as possible. EVIDENCE: The home has a care plan for each service user. The plans demonstrate a thorough needs assessment, which clearly set out how current and anticipated needs would be met. Service user’s needs are assessed regularly at review meetings. The manager stated that the service user plans are reviewed every six months; this was a requirement from the last inspection. Service users are consulted and are encouraged to make decisions in all areas of their life. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 11 It was evident that service users take an active role in the daily operation of the home and are involved in planning menus and arranging their social/leisure activities. Service user meetings are held and give service users the opportunity to reflect on the services provided. Service users at the home have individual risk assessments depending on their needs and goals. Copies of individual risk assessments are kept on the service users file and cover a variety of situations including learning new skills and going out in the community. The home has a confidentiality policy and also guidance on the Data Protection Act 1998. Staff and service user files are kept in a locked facility in the office. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 12 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 standard(s) 11,12,13,15,16 and 17 Service users are adequately supported to participate in the local community, with the aim of maximum integration. Service users are supported to continue education and appropriate activities, so that they can maximise fulfilment and achievement in their lives. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: The service users assist with weekly shopping, menu planning, and household chores. Both service users have a high degree of independence. One service user explained that she was still looking for employment. It was clear that staff at Graceland support service users to continue their education or training, and / or take part in valued and fulfilling activities. The other service user attends South Norwood and Croydon College on a regular basis. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 13 The home is well located for access to local community facilities. It was evident that both service users participate in a wide range of social activities within the local community and are encouraged by staff to pursue their preferred choices whenever possible. Activities include bowling, shopping and discos. There was evidence of the home enabling good links with family and friends who can visit and are visited regularly. The inspector met one of the service users mother who gave a positive about the care in the home. The daily routines at Graceland clearly promote opportunities for service users to maintain, or further develop their personal skills in areas such as money / household management and personal relationships. Activities such as cooking, cleaning and self-care are a normal part of the daily life for service users in this home. It was required that the home’s rules on smoking, alcohol and drugs be added in the Service User’s Guide. This has been complied with. The service users design their menus with appropriate support from staff if required. The home menus are seasonal and based on the likes and dislikes of the service users. Planned menus are recorded. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 and 21 Service users’ personal care needs and physical and emotional health needs are met well by this home. This ensures that the service users’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. However service users and/or relatives should be consulted about their last wishes. EVIDENCE: Encouragement and guidance are provided to support personal care but direct personal care is limited at this home. Evidence has been presented in discussions with staff of them having knowledge of good practice in providing care and support, and this has been confirmed through observation. The service users are registered with the same medical practice and are supported by staff to access other services. Health records sampled at random indicate that GP’s and other medical/health care professionals are being contacted as and when required, and records of these appointments are appropriately maintained. The home has a medication policy and procedure. The current service users are not on any medications. The manager still has to organise an in house Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 15 training session on medicines and their safe handling. This was a recommendation from the last inspection. The manager must consult both service users and/or their respective families about their last wishes and this must recorded in their personal files. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. The home’s policies and procedures help protect service users from abuse and help staff if they need to tell someone about any bad care practice they may see. EVIDENCE: The complaints procedure was clear and contained all of the elements required to meet Standard 22 including a minimum response time of less than 28 days. However the manager must change the name of the regulatory organisation to the Commission For Social Care Inspection. There had been no official complaints at or since the last inspection. The home has policies and procedures in place to safeguard service users from abuse including whistle blowing. The manager confirmed that she has received formal training on adult protection but the other staff are still waiting for a date to attend the training. Until this has been achieved, the manager explained that she plans to organise an in house training event on abuse awareness using video resources and discussion. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 17 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 standard(s) 24,29 and 30 The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional wellbeing. However a fire safety inspection still needs to be carried out. EVIDENCE: The home is a normal family home; it meets the needs of the service user. The home is clean, well presented and furnished. . To ensure that the premises comply with the requirements of the local fire brigade (LFEPA), the Registered Provider was required to arrange for a safety inspection to be carried out by the fire service with a report made available to inspection. This remains outstanding and will be repeated. No aids or adaptations have been deemed as necessary at this time for either of the service users. The home was clean and hygienic and free from offensive odours throughout on the day of the inspection. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34,35 and 36 More diligence is required in the taking up of staff references and checking criminal records, as without these there is a higher risk of employing unsuitable staff and impinge the safety and protection of service users. No progress has been made with regards to the frequency of staff supervision. This area therefore remains unsatisfactory. EVIDENCE: The staffs within the home have clear job descriptions and are aware of their roles and responsibilities. As an existing care home, staffing levels are based upon the guidance issued under the Registered Homes Act 1984. There is one staff on duty per shift, with a member of the staff team also sleeping in at the home at night, available to offer support if needed. One of the staff members is a foreign student; the manager is reminded that she must adhere to the employment law regarding working hours. Staff records were examined and were seen to contain references, criminal record checks, original application forms and copies of identification. One of the staff files sampled did not have any criminal record check and another one had one reference only. The manager was reminded that that no new staff Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 19 may commence duties until the home is in receipt of a valid CRB check and POVA clearance. The manager must ensure that staff files must contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001. The home has also devised its own induction training pack relevant to the service provided and the service users needs. It was a requirement from the last inspection that there is documented evidence that all new staff employed in the home, have completed an induction process. This is now in place. An up to date appraisal record for staff was available but no records of formal supervision. The Manager must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39 and 42 The home management generally provides leadership, guidance and direction to staff to ensure service users receive consistent quality care. However an annual quality development plan still needs to be developed. EVIDENCE: Throughout the course of the inspection the manager demonstrated a good competent management skills. She has many years experience of working with this client group and displayed an insight into the relevant issues. The manager has been seen to actively maintain an open and inclusive relationship with staff and service user. She operates an open door policy for service users, one was observed freely raising issues directly with her. The home has a satisfaction questionnaire for service users and their relatives to gain feedback on the services being provided. The manager explained that Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 21 an annual quality development plan still needs to be developed for the home and this requirement therefore still stands. The inspector examined certificates relating to health and safety. Up to date servicing certificates were in place. Risk assessments covering safe working practices have yet to be completed for the premises and the former requirement therefore still stands. The home must ensure that the COSHH cupboard is kept locked at all times when not in use. Graceland Care Home G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score 3 x 3 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Graceland Care Home Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x 2 x G53 S25785 Parchmore113 V198498 190505 stage4.doc Version 1.30 Page 23 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 1 Regulation 4 and 5 Requirement Timescale for action 31/08/05 2. 21 3. 24 4. 34 5. 34 The home needs to review the Statement of Purpose and Service User’s; to include all information in Regulation 4 and 5 respectively. 12(3) The manager must consult both service users and/or their respective families about their last wishes and this must recorded in their personal files. 23(4) To ensure that the premises comply with the requirements of the local fire brigade (LFEPA), the Registered Provider must arrange for a safety inspection to be carried out with a report made available to inspection.Previous timescale of 30/04/05 not met. 17(2) CRB checks and POVA clearance sch.4(6)1 (for staff employed after April 9(1)(b,c)S 2004) must be completed for all ch.2 (6 & staff employed at the home.The 7) registered provider must ensure that any future employees obtain a CRB and POVA check before they commence work. 19 The manager must ensure that staff files must contain all relevant documentations as per schedule 2 of the revised Care G53 S25785 Parchmore113 V198498 190505 stage4.doc 31/08/05 31/08/05 31/07/05 31/07/05 Graceland Care Home Version 1.30 Page 24 Homes Regulations 2001. 6. 36 17(2) 18(2) The registered provider must ensure that all care staff have regular, recorded supervision. (Timescale of 24/01/05 not met) 21(2) The home must produce a 24(1)(a)( written record of an annual b) quality development plan.(Timescale of 30/04/05 not met) 13(4)15(1 The home must ensure that ) Sch.3,3q environmental risk assessments are completed for all safe working practices as listed in standards 42.2 and 42.3. (Timescale of 30/04/05 not met) 13(4)(a) The home must ensure that the COSHH cupboard is kept locked at all times when not in use. 31/07/05 7. 39 31/08/05 8. 42 31/07/05 9. 42 31/07/05 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 36 Good Practice Recommendations It is recommended that the manager keeps a yearly record of staff supervision signed by both the supervisor and supervisee for easy monitoring. 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