Inspection on 30/04/07 for Gracelands

This inspection was carried out on 30th April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gracelands 25/08/09

Gracelands 27/05/09

Gracelands 17/10/07

Gracelands 16/11/06

Gracelands 21/02/06

Gracelands 16/08/05

Gracelands 07/02/05

Gracelands 20/08/04

Gracelands 25/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Gracelands Ellesmere Road Whittington Oswestry Shropshire SY11 4DJ Lead Inspector Sue Woods Key Unannounced Inspection 30th April 2007 09:45 Gracelands DS0000038691.V336015.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 Gracelands DS0000038691.V336015.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. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gracelands Address Ellesmere Road Whittington Oswestry Shropshire SY11 4DJ 01691 652153 01691 652153 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) www.loppingtonhouse.co.ukE mail office@loppingtonhouse.co.uk Loppington House Limited Miss Julie Palin Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Gracelands is registered with the Commission of Social Care Inspection (CSCI) to provide accommodation and care for seven people with a learning disability. The home is situated in the village of Whittington in North Shropshire. Loppington House Ltd owns the home and the Registered Provider is its Director, Mr Paul Harris. The Registered Manager for Gracelands is Ms Julie Palin. The seven people living at Gracelands had previously lived at Loppington House and were chosen carefully for their compatibility. Accommodation is spacious and all bedrooms are single. People who use the service and their representatives are able to gain information about this home from the Statement of Purpose, Service User Guide and inspection reports produced by Commission for Social Care Inspection. Inspection reports can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk The Weekly fees charged range from £842.32 - £894.16 Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Gracelands took place on 30th April 2007. It started at 09.45 am and was carried out over a period of six and a half hours. The inspection included discussions with two service users and an observation of care experienced by six of the people using the service. The inspector also spoke with staff and senior staff on duty, looked in detail at all aspects of care for two people and examined a number of records. Due to the complex needs of people living at Gracelands it was not possible to directly obtain the views of all service users as to the quality of service provided. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Younger Adults and to review progress made by the home since the last inspection undertaken on 16thth November 2006 when thirteen requirements and one recommendation were made. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The registered manager was on annual leave on the day of the inspection but came in to support the process. Following the inspection immediate requirements were made in relation to the need to safeguard service users. The manager was in full agreement of the requirements and within 48 hours produced an improvement plan to address issues. The inspector would like to thank everyone who contributed towards and supported the inspection. What the service does well: Staff stated that Gracelands is run ‘like a family home’. Other comments suggest that staff work well as a team and that service users are well looked after. Service users who spoke with the inspector said they liked living at Gracelands. Staff are motivated and enthusiastic, enjoying their work and receiving good support and training opportunities. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: At the time of the last inspection of the home (November 2006) concern was expressed in relation to incidents taking place between service users. It was considered that necessary safeguards needed to be implemented to protect the rights of all service users to live free from physical assault and intimidation. At the time of this inspection it was found that this has not happened and service users remain vulnerable and at risk of harm. It is for this reason that immediate requirements were made for the manager to assess the current situation and make a referral to the adult protection team as well as to review staffing levels and seek professional input to review behaviour management guidelines. Regular opportunities to access community activities are not happening due to the current situation within the home. This was a requirement at the time of the last inspection of the home. Other requirements have been made to improve the quality of life for service users including the need to review care and support plans to reflect consistency, safe and current best practice and to update policies and procedures to reflect good practice and current legislation. In addition areas for staff training have been identified in relation to managing people whose behaviours challenge the service. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 7 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. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 8 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 Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 9 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): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives are provided with information about what the service offers and the terms and conditions of residency. EVIDENCE: Gracelands does not currently have any service user vacancies and the people living at the home have been there since it first opened in 2002. The judgement to support this outcome group has been carried forward and reflects initial admissions procedures that were very thorough. The Service User Guide was seen to contain details of fees charged and the manager stated that this will be reviewed to reflect current fees. A copy of the document was seen on both files reviewed although not in an easy read format. This reflects the fact that service users representatives are the people who would be reviewing such information. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7,and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Individualised care and support plans mean that service users needs can be generally met reflecting their personal preferences while minimising identified risks. EVIDENCE: Care plans were reviewed for the two service users case tracked as part of the inspection. Detailed information was available and staff in discussions with the inspector felt that these documents were useful and gave good information in relation to service users care and support needs. Support plans in relation to managing challenging behaviours have been developed by the manager and a representative from Loppington House. It was positive to note that the team are currently being supported by a nurse from the local authority learning disability team and a behavioural psychologist to assess one service user whose challenging behaviour is escalating and having a negative impact on the lives of others living in the home. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 11 Similar input has been requested for a second service user. A review of incident forms from 16/03/07 to 22/04/07 identified 28 incidents some resulting in injury to service users. Existing plans are not sufficiently safeguarding service users and some care practices do not reflect current good practice (the use of sanctions and warnings). The homes physical intervention policy was last reviewed 2004 and although the MAPA guidance is available on file no one has received training to implement it. The home’s policy does not reflect practice within the home. Note: Following an immediate requirement made at the time of the inspection the manager has instigated support and input from the a social care professional who was already working with the home to review management support plans and together they have implemented some interim safeguards in relation to support strategies. This prompt action was considered when assessing the quality rating for this outcome group. There was evidence that care plans have been reviewed by the manager this year and that they were reviewed last year by an independent advocate from a local advocacy service. On files reviewed some goals have been identified in relation to household tasks. The manager stated that the Person Centred Planning process has started and service users are working through it at college on Wednesdays. A planning tool in relation to health action planning was seen on one file reviewed. The inspector was able to observe interactions between staff and service users at various times during the day. Staff were polite and courteous, offering choices, for example, in relation to what people were wearing and who they were travelling with to the day service. The atmosphere at the home was relaxed and friendly. The staff member who introduced service users to the inspector was aware of small details that made a difference to the way interactions took place. Service users are able to help develop menus and it was evident that service users liked the meal that was planned for the evening. The meal planned for the following night was a particular favourite of one service user and this was later seen recorded in his care plan along with other likes and dislikes. Risk assessments were seen on both files reviewed and control measures reflected practice observed and discussed on the day. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from maintaining links with family members and by participating actively in meal planning and preparation however opportunities to participate in community activities are limited due to the current situation within the home. EVIDENCE: At the time of the inspection the manager stated that currently opportunities for service users to access activities within the local community are limited due to staffing levels and the impact of the behaviours of one service user on the others. Concerns in relation to opportunities for service users were raised at the time of the last inspection of the home by staff and a recommendation was made to monitor the relationship between activity levels and behaviour that challenges. There was evidence on an incident form that one service user had been bored leading up to an incident. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 13 A review of financial records for two service user revealed limited spending activity although both went out for tea on one day and both participated in an activity day. Note: Following the inspection the registered manager has arranged for staffing levels to be increased as an interim measure to use the services of a sister home to support service users to go out and participate in activities. Again this prompt action was considered when assessing the quality rating for this outcome group. Care plans reviewed contained information about family contact arrangements identifying days for letter writing. Service users receive letters and postcards for family members and representatives are invited to attend reviews. One service user had visited his family for a holiday over Easter and one service user is currently spending three weeks with his family. Issues in relation to individual rights will be reviewed in the outcome section ‘Concerns and Protection’. Gracelands has developed a five weekly menu. During group discussions it was identified what service users were having for tea on the evening of the inspection. This was later confirmed by reviewing the menu. Menus reflected a varied and balanced diet for service users and the identified dietary needs for one service user were catered for while enabling him to eat the same as the others. Service users who spoke with the inspector said they liked the food. Service users support staff to prepare evening meals. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users benefit from a staff team who pay attention to meeting their personal care needs and are safeguarded by safe systems in place for the storage, administration and recording of medication. EVIDENCE: At the time of the inspection staff were seen to pay careful attention to detail in relation to service users looking well groomed. All service users have their own clearly labelled grooming products and service users retain their own toiletries if this is appropriate. At the time of the last inspection of the service it was found that one care plan did not direct staff as to how blood sugar levels should be monitored. This remains the case although the manager was knowledgeable about the procedures. Arrangements for one service user have been made to see an optician at his home after he was unhappy to attend the local surgery for screening. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 15 Records in relation to health appointments were in the process of being updated onto individual care files. Likewise weight monitoring for one service user is not yet being recorded on her personal plan. Since the time of the last inspection of the home arrangements for the storage, administration and recording of medication have improved. No gaps were identified on MAR sheets reviewed at random and the manager stated that her and the senior care worker make regular checks to monitor practice. A signed form (by the GP) is in place for all service users to support the use homely remedies and the manager stated that it will be reviewed during health care check ups or if medications change. A recent medication error had been appropriately referred to CSCI for notification and the use of a PRN medication was appropriately documented and cross-referenced an incident form seen by the inspector. The home is currently being supported by a suitably qualified person to introduce protocols to support the use of PRN medications. These will provide additional safeguards when implemented. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home has not followed safeguarding procedures; some service users are vulnerable and at risk of physical harm from the identified behaviours of others. EVIDENCE: Part of the complaints policy was reviewed during the inspection. It was positive to read that the organisation has a pro-active approach to complaints offering reassurances that issues will be resolved informally wherever possible. All staff who spoke with the inspector said they were aware of the homes complaints procedure and the whistle blowing policy. Staff commented that they would feel confident to raise issues in relation to poor practice but all added that they had no concerns in that area. The two service users who were able to speak with the inspector felt that staff listened to them. Behaviours also demonstrate when service users are unhappy and the manager has been proactive in making referrals to relevant health care professionals to get support to establish why behaviours are happening although resources cannot support all referrals. Current support guidelines are not sufficiently protecting service users. Although most staff have received training in adult protection it was identified during the inspection that the quality of life for some service users is being compromised by incidents where they have been physically assaulted by others. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 17 The manager agreed that this was unacceptable and committed to initiate adult protection referrals in order to protect vulnerable service users. A requirement made at the time of the last inspection of the home identified that action must be taken in response to all incidents of abuse including service user to service user. This requirement has not been met although the manager stated in a safeguarding adults meeting on 09/05/07 that she had been unclear what the requirement related to. The homes protection of service users policy is very general and has not been reviewed since 2004. The policy did not refer to making referrals to the safeguarding adults’ teams. Strategies for managing identified behaviours are in need of urgent review as the home uses as process of sanctions and warnings (seen recorded in care plans and reflected in conversations with staff on duty at the time of the inspection). These practices are inappropriate and compromise human rights legislation e.g. the practice of taking something away from someone that they enjoy as a consequence of behaviour. (At the time of the safeguarding adults meeting the home gave reassurances that these practices have stopped.) It was not possible to see how the practice of ‘safe escorting’ works although the manager and the senior support worker cascade the training to staff. Note: Following an immediate requirement the manager contacted CSCI on 2nd May 2007 to confirm that referrals have been made to the adult protection team and a named social care professional is managing the process. A meeting took place on 09/05/07. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 18 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): Standards 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The environment provides homely, domestic style accommodation for service users with sufficient space to meet their needs. Routine safety checks and recent improvements have made the home a safer place for service users to live. EVIDENCE: The inspector was given a tour of the home. All areas were seen to be clean and tidy. The manager identified that bathrooms are due for refurbishment this year and communal areas have been redecorated. All bedrooms were seen to be spacious and personalised. Changes have been made to one service users bedroom in order to make it safe for him. There was no evidence that fire doors were being propped open as identified during the last inspection and all environmental safety checks were up to date. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 19 As a result of an incident with a service user all glass has now been covered with a safety film. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 20 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): Standards 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There may not be sufficient staff on duty to keep service users safe however following the inspection the manager has taken steps to risk assess staffing levels offering better protection. Service users benefit from being supported by a committed and enthusiastic staff team. EVIDENCE: At the time of the inspection there were two staff on duty and two staff had arrived to support service users to their daytime activity. The rota supported this arrangement. The manager advised that there should be three staff on duty at all times although a review of the rota suggested that this was not always the case. The manager reported that the home is currently covering three staff vacancies and the long-term sickness of an established member of staff. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 21 This arrangement is putting a strain on everyone although it is to the staff teams credit that they work together to cover shifts where possible and in discussions staff were enthusiastic and positive about the home. Given that some incidents that happened recently took place when staff were doing other things (like administering medication) and that following an incident two staff may be required to safely escort a service user to another room urgent consideration must be given to staffing levels within the home. Staffing levels, at this time are also meaning that service user cannot access individualised community services and given that one service user following an incident stated that he had been bored, this may mean that staffing levels are impacting negatively upon the behaviours of service users. Note: Following an immediate requirement at the time of the inspection the manager has responded to CSCI (on 2/5/07) that staffing levels have been reviewed and that the proprietor has committed to making available additional resources as required. Following information shared at the safeguarding adults meeting on 09/05/07 it was agreed that four staff would be on duty at key times. This agreement was considered when assessing the quality rating for this outcome group. All staff who spoke with the inspector felt well supported and trained. Staff stated that they enjoyed their jobs and this was reflected in the positive interactions seen on the day of the inspection. Not all staff have attended training to support people with challenging behaviours although in discussions staff referred to procedures recorded on individual files. Two staff files were reviewed and found to contain all required information. The manager was made aware of the procedure for storing and disposing of CRB disclosures when they have served their purpose. Staff spoke of regular training opportunities although formal training records were not reviewed on this occasion. It was positive to see that certificates were on files reviewed to support staff comments that they had recently received training in epilepsy and diabetes. Since the time of the last inspection the manager has received ‘competency forms’ to support that all agency staff have appropriate checks and qualifications for the job they are required to do at Gracelands. It was reported that staff meetings take place on a regular basis. The senior care worker stated that these meetings are used to share procedures Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 22 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): Standards 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a committed manager who creates an open and positive atmosphere from which service users benefit. However urgent input is now required from internal and external sources to work together in safeguarding service users. EVIDENCE: The manager was on annual leave on the day of the inspection but came in anyway to support the process. Since the time of the last inspection the manager and the senior care worker both reported that they are receiving more support and supervision form senior managers. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 23 However the manager still only has two days a week for management tasks and recent issues and staffing shortages have meant that she has even less time. The inspector acknowledged that the current situation at the home is putting a strain on all resources and it is a credit to the home that morale remains high. However the situation is not sustainable long term and the manager needs to review the situation with senior managers and implement a plan to ensure all service users and staff are appropriately safeguarded. A letter received following the inspection on 2nd May 2007 suggests that this process has started. Despite all the challenges currently facing the manager she has developed and sent out surveys to relatives as part of the homes quality assurance process. Staff are due to receive questionnaires shortly and service users views will be obtained by a named advocacy worker. Records suggest that health and safety checks are carried out on a regular basis. The inspector did not see the contents of the COSHH cupboard at the time of the inspection however the duplicate set of data sheets were seen readily available. The use of these products is supported by a generic risk assessment that doesn’t make reference to the use of personal protective equipment. The manager stated that a new format is currently being developed that contains all such information in an easy read format. The manager stated that the home has met the requirements made by the fire safety officer at the time of his last inspection (March 2006) and fire risk assessments had been reviewed in April 2007. Water temperatures were checked and found to be safely regulated. Records also supported this finding. The manager is aware of her responsibilities in relation to reporting incidents that affect the health and wellbeing of service users to CSCI however this is not happening for all incidents. The manager has had discussions with CSCI in relation to meeting this standard. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X X 3 X Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 25 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 YA13 Regulation 16(2)(m)(n) 14 15 Requirement The Registered Manager must ensure that service users are supported to participate in the local community in accordance with assessed needs and the individual plans. New Requirement November 2006 Timescale for action 31/03/07 unmet. 2 YA23 13(6) Appropriate action must be taken in response to all incidents of abuse including service user to service user to protect the interests of all service users. New Requirement November 2006. Timescale for action 01/03/07 unmet. 28/05/07 Timescale for action 04/06/07 Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 26 3 YA6 15 (2) (b) 4 YA6 12 (1) (a) (b) 5 YA19 12 (1) (a) (b) 6 YA23 13 (6) Care and support plans must be reviewed to ensure that they reflect safe and current best practice guidelines to establish that incidents of challenging behaviour can be safely managed within the home and within the community. The homes policy and procedure in relation to physical intervention must be reviewed and updated to reflect safe working practices that support service users and staff. There must be clear guidance available for staff to follow to ensure they can offer appropriate and consistent support in relation to identified medical conditions The homes policy on the protection of service users must be reviewed and updated to ensure that it instructs staff as to how to safely support and protect service users from harm and abuse. The policy must also make reference to the procedure for making referrals to adult protection teams when staff and manager believe service users are at risk of harm and abuse. Staff must receive training appropriate to the needs of people living at Gracelends from people who are competent and qualified to do so in relation to managing challenging behaviour. 25/06/07 04/06/07 28/05/07 04/06/07 7 YA23 18 (1) (a) 25/06/07 Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 27 8 YA33 18 (1) (a) The home must ensure that there are sufficient staff on duty at all times to ensure the safety of service users and to enable them to participate in in-house and community based activities to enhance their quality of life 21/05/07 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. Refer to Standard YA23 Good Practice Recommendations It is recommended that the Registered Manager monitor the relationship between activity levels and behaviour that challenges. New Recommendation November 2006. 2 3 YA37 YA42 It is recommended that the manager reviews her working hours in relation to carrying out management tasks to ensure she has sufficient time to carry out her role. The manager should ensure that she is clear as to what incidents that occur within the home must be referred to CSCI and other professional bodies. Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gracelands DS0000038691.V336015.R01.S.doc Version 5.2 Page 29 - 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. 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