Inspection on 21/02/06 for Grammar School House

This inspection was carried out on 21st February 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grammar School House 25/10/06

Grammar School House 05/10/05

Grammar School House 08/02/05

Grammar School House 17/08/04

Grammar School House 30/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Grammar School House York Road Earls Colne Colchester Essex CO6 2RB Lead Inspector Kathryn Moss Unannounced Inspection 21st February 2006 10:15 Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grammar School House Address York Road Earls Colne Colchester Essex CO6 2RB 01787 222412 01787 221814 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) Grammar School House Limited Mrs Janine Formoy Care Home 13 Category(ies) of Learning disability (13), Physical disability (13) registration, with number of places Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability who may also have a physical disability (not to exceed 13 persons) 5th October 2005 Date of last inspection Brief Description of the Service: Grammar School House is an older style property, situated in the village of Earles Colne, with access to local towns. The home is divided into two selfcontained units, one (the ‘annex’) for six more independent service users, and the other (the ‘seven-side’) for seven more dependent service users. Each side of the home has its own lounge and dining areas, and a small kitchen; both sides share laundry and garden facilities. All service users have single bedrooms. At the time of this inspection there were twelve service users in residence. The home is registered to provide care to thirteen younger adults with a learning disability and/or physical disability. Although a learning disability is the primary need of current service users, one or two have an additional physical disability or medical condition (e.g. epilepsy). The home is owned by Caring Homes Ltd. and the registered manager is Janine Formoy. The inspector had been advised on previous inspections that the home prefers to refer to service users as ‘clients’, and so this term will be used in this report. Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 21/2/06, lasting six hours. The inspection process included: discussion with the manager and three staff; discussion with two clients and some time spent with other clients; the viewing of communal areas, laundry and kitchens; and inspection of a sample of records. The main focus on this inspection was on health and safety, the maintenance and refurbishment of the property, and reviewing requirements from the last inspection. 13 standards were inspected, and 4 requirements and 11 recommendations have been made. Two of the requirements have been carried over from the last report, as the home is still within the previous timescales set for meeting these requirements. The clients spoken to were positive about the staff and about their current lifestyle at Grammar School House. Other clients who were spending time in the home were observed to appear content and to respond well to staff. What the service does well: What has improved since the last inspection? Since the last inspection, the home had appointed a new deputy manager and consolidated the senior team: this had enabled senior staff roles to be clarified and had improved the delegation of and implementation of responsibilities within the home (e.g. staff supervision). Although further ongoing action was required in relation to some areas of training, the home had provided a number of areas of training over the last year, including epilepsy, challenging behaviour, COSHH, first aid, moving and handling, diabetes awareness, and medication administration. Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 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. Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. EVIDENCE: Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The home supports service users to make decisions about their lives. EVIDENCE: Where they had the capacity to make decisions about aspects of their lives, clients at Grammar School House were supported and encouraged to do so. Examples noted during the inspection included: daily activities, whether to go out, where to spend their time, what to spend money on, holidays, etc. Staff were able to describe how clients were provided with a range of possible options (e.g. in relation to activities, meals, etc.), and how they consulted with clients and sought their ideas and views (e.g. through meetings). Staff also described how choices were made on behalf of individuals who were not able to make decisions for themselves, using knowledge of what each person liked or disliked and observing how they responded to new experiences . Three clients managed their own money, with assistance and guidance from staff where necessary (e.g. to keep money safe, and to advise on purchases, etc.). The pre-inspection questionnaire completed by the manager indicated that the manager is the appointee for nine clients in relation to their DSS benefits. Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 and 17 The home encouraged and supported clients to maintain appropriate family and personal relationships. Clients were offered a healthy, varied and balanced diet. EVIDENCE: Staff were able to describe ways in which the home supported clients in maintaining relationships with their families, including encouraging visitors, facilitating telephone calls and maintaining communication with family members, and by taking clients to visit their families. There was also an example of staff supporting one person in their wish not to visit a family member. Several clients participated in activities in the local village (e.g. attended church, went to events at the village hall, used local shops). The home also provided opportunity for clients to attend a number of local clubs and day centres, enabling them to develop friendships with other people attending those groups. The home had a four weekly rotating menu, based on knowledge of clients’ likes and dislikes and on feedback from the clients in the annex. The menus Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 11 viewed showed a good range of balanced meals, and staff reported that there was flexibility to change the menu to meet day-to-day needs and wishes. Clients spoken to had enjoyed their lunch on the day of the inspection, felt that they had a say in what they ate, and said that staff were good cooks. A senior carer was positive about the quality and quantity of food available to clients, and reported that there were no budget restrictions affecting their planning of menus. ‘Shopping lists’ showed that staff had the freedom to make suggestions and to identify products needed. It was good to see evidence of plenty of fresh fruit available to clients. The home maintained clear records as to whether clients had ate well, moderately or poorly, with scope to record any relevant issues. At the time of this inspection, the dining room on the seven-side was in a very poor condition and did not provide a pleasant or suitable environment for clients to eat their meals in (see further comments in Environment section). Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. EVIDENCE: Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home had appropriate systems for responding to complaints, and clients felt that they could raise concerns and that these would be addressed. The home had information and policies that promote the protection of vulnerable adults, but the home’s procedure for responding to concerns needed revision to reflect local multi-agency agreements. EVIDENCE: The home’s complaints policy and procedure was not viewed on this occasion, but the manager confirmed that there is a copy of this in each client’s room and also in the home’s statement of purpose and service user guide. Clients spoken to were clear that they could raise any concerns with the manager. The home kept a record of any complaints received, recorded on a standard complaint form that showed the nature of the complaint and the action taken. The manager was advised to ensure that this record also shows the outcome of the complaint. The complaint log included details of four complaints received over the last year, and the action taken to address them. The CSCI had also been notified of a recent complaint that had been appropriately investigated and responded to by the organisation. The protection of vulnerable adults (POVA) was only discussed in relation to outstanding requirements and recommendations from previous inspections, when it had been noted that the home had information and policies that promoted the protection of vulnerable adults, but that these did not fully reflect local multi-agency protocols for responding to suspicion of abuse. The Responsible Individual confirmed that work was in progress to revise the home’s procedure for responding to evidence or suspicion of abuse, and it was noted that this was still within timescales agreed with the CSCI after the last Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 14 inspection. Although the home had delivered training to staff using a training video, no other training in POVA had been provided to staff since the last inspection: the manager had not yet been able to attend a Trainer’s course for this, as initially planned, and discussed the possibility of using another trainer within the organisation. It was recommended that action on this be progressed. Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 and 30 Some areas of the premises were not maintained in a satisfactorily homely and safe condition at the time of this inspection. Areas of the home viewed were clean and hygienic. EVIDENCE: The home is situated in a village location, with access to local amenities and buses (although the home has its own transport that is used for most clients). The home provides accommodation in two separate units of six and seven clients respectively. All clients have a single bedroom: bedrooms were not viewed on this visit, but it was noted that an empty room and two other rooms were in the process of being decorated. On previous inspections it had been noted that bedrooms were decorated in bright and cheerful colours. On the previous inspection the inspector had been advised of a plan of work for the home for the last year that included: the replacement of lounge furniture (sofas), the refurbishment of both kitchens, the refurbishment of the sevenside bathroom, and the decoration of the seven-side dining room. On this inspection it was noted that the new lounge furniture was now in place, one kitchen had been refurbished, and work was in progress on the bathroom (in which an assisted bath was to be installed). This was good to see. The Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 16 manager also advised that consideration was being given to installing an additional ‘wet room’ shower facility. However, several issues of maintenance and repair raised some serious concerns during this inspection. The dining room was in a state of considerable disrepair, partly due to an outstanding need for decoration, but also because the floor had been dug up at the beginning of January to repair some pipe work, leaving uncovered replacement boarding that was not washable and had gaps between the boards. This presented an unsightly environment for clients to eat their meals in, as well as being a potential infection control hazard as it could not be adequately cleaned. At the point of the inspection the manager had still not been given a timescale for the replacement of the floor covering: enquiries made during the inspection indicated that the new floor covering was on order and the estimated delivery time was a further two weeks. This is not an acceptable time period for the dining room to be in such a poor condition. Of similar concern was the fact that work had started on the bathroom the previous day, but the manager had not been given warning of this or been advised of a clear time period for the completion of the work. Enquiries made during the inspection indicated that the work could take two weeks: over that time the home would only have one functioning bathroom (plus an additional ensuite shower unit in a bedroom) for twelve clients, five of whom were doubly incontinent; additionally the home would have no assisted bathing facilities available for a client who required the use of a hoist to access a bath. Whilst it was good that this bathroom was to be improved, there did not appear to have been any consideration of clients’ or staff’ needs in the planning of this work by the organisation. Further concerns related to the way maintenance work was organised by the provider. A local maintenance person attended the home one day a week for minor repairs, health and safety checks and decorating. However, all other maintenance work and purchases had to be requisitioned through the property department of the organisation. The home’s records showed prompt action by the manager in notifying this department of work or items required, but that that there were frequently long delays in getting these actioned, and evidence that the manager and Responsible Individual had often had to follow up requests with further requisition notices, memos and management reports. In some cases it had taken many months to get action on serious issues: for example, a leaking roof in on client’s room had taken over three months (and several requests) to get repaired; a statutory requirement made by the fire officer regarding fire door signs had taken eight months to address; an immediate statutory requirement by the environmental health officer in June 2005 for a fly screen in the kitchen had still not been actioned, etc. This is not acceptable practice in relation to the maintenance of the home and as a response to statutory requirements. Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 17 The home kept records of maintenance work identified and carried out: the manager was advised to ensure that these clearly showed when work had been completed. Routine decoration and refurbishment had not previously been recorded, but the manager stated that this will now be recorded on the monthly health and safety audits being carried out by the manager and responsible individual. It was noted during the inspection that some of the carpets in corridors and lounges were marked and in some places worn. The manager advised that funding has been agreed to replace the flooring in the corridor on the seven-side of the home. The lounge on the seven-side of the home did not present a warm and homely environment for clients: whilst the awkward shape of the room and the difficulties associated with some clients’ behaviours were noted (re the risk of having any breakable items in the room), the manager was advised to consider ways of improving this room (e.g. colours, lighting, carpet, etc.). On the day of the inspection, areas of the home viewed were clean and tidy, and were free from any offensive odour. The home has a laundry room that is situated away from areas where food is stored or prepared, and which contains washing and drying facilities, a sluice sink, and a hand basin with liquid soap and paper towels. There was a clear system in place for separating washing loads (normal, soiled, kitchen, etc.), and staff confirmed that disposable protective gloves were available and were used for all handling of laundry. Both washing machines were domestic style machines that had set 60°C and 95°C washing cycles. This was discussed with respect to the need to meet infection control guidelines (i.e. that items soiled with body fluids should be washed at a temperature of at least 65°C for a minimum of ten minutes), and it was recommended that laundry practices were reviewed to ensure that all staff used appropriate washing cycles for soiled items. Policies and procedures in relation to infection control were not reviewed on this inspection. Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 36 The number and skill mix of staff was sufficient to meet the needs of current clients. Action had been taken, or was in process, to ensure that staff had received appropriate training to fulfil their roles and to meet clients’ needs. Appropriate formal and informal systems were in place to support and supervise staff. EVIDENCE: Rotas were not viewed on this occasion, but staff reported that the home aims to maintain the agreed staffing levels of five staff throughout the day. They felt that this was sufficient to meet the needs of clients, in conjunction with some additional weekly one-to-one support hours for a specific client. The home also employs a part-time activities co-ordinator, whose input staff found helpful in organising and initiating activities. Since the last inspection, the senior staff team in the home had been developed further, including the appointment of a deputy manager: this appeared to have had a positive impact on the way the home was managed and run. Training was reviewed in relation to requirements and recommendations made at the last inspection. Since the last inspection, action had been taken to provide staff training in first aid and in moving and handling: although not all staff had attended moving and handling training, this was a good start, and the manager confirmed that further sessions were being planned. Staff also Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 19 reported that there had been some training in infection control and COSHH, and it was noted that food hygiene training was booked to start in March. The manager currently had responsibility for assessing staff competence to administer medication, and three more senior staff were due to do a distance learning course in medication. It was noted that eleven staff had attended a session on Physical Intervention, and that further training in Breakaway techniques was being planned. A previous requirement carried forward over several inspections related to the need for staff to be provided with training to develop skills for communicating with clients in the home. This training had still not taken place, but the difficulties in accessing this training had previously been noted. On this occasion the manager confirmed that a speech and language therapist had now assessed three of the clients, and had promised to prioritise the home for Total Communication training. This remains a requirement, but the action being taken to address this was acknowledged. Following a previous requirement, the home’s formal staff supervision processes were discussed with the manager. Since the last inspection, good progress had been made in establishing and developing the senior staff team within the home: each senior staff member now had responsibility for supervising a number of care staff, and the manager supervised the senior staff. The manager maintained a Supervision Log showing when each person had received an individual supervision, and this showed that each staff member had received a supervision session over the last two months. The manager confirmed that they were aiming for supervision to take place every two months, and that written records were maintained. Staff meetings were not specifically discussed on this occasion. Staff spoken to felt well–supported by the manager and deputy manager. Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The manager is appropriately qualified and experienced to run the home. The home is run in the best interests of residents, with systems in place for monitoring this. Practices in the home promote the health and safety of residents and staff. EVIDENCE: The registered manager has appropriate experience to manage the home: she attends relevant training as required, has previously completed NVQ level 4 in management, and is currently undergoing the Registered Manager’s Award and additional units to attain NVQ level 4 in care. The senior care team had been developed further since the last inspection, with the appointment of a deputy manager and allocation of specific roles and responsibilities: this appeared to have had a positive impact on the day-to-day management arrangements in the home. The Responsible Individual advised the inspector that the Registered Provider was developing the organisation’s Learning Disability services, and had recently established a specialist division of the organisation to develop policies, practices and training appropriate to the needs of clients Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 21 with a learning disability. This appeared to be a positive initiative that should have beneficial outcomes for the home in the future. The organisation’s quality assurance department is responsible for implementing quality assurance processes, including sending out annual survey forms to clients and staff and evaluating the responses. Only three clients in the home were currently able to complete these: there were no systems for evaluating the quality of care in relation to clients who were not able to provide verbal feedback, but the responsible individual hoped that the new learning disability directorate would develop work on this. Other quality assurance processes in place, included: ISO 9002, regular monitoring visits by the responsible individual, internal audits by the manager and responsible individual (e.g. health and safety), organisational audits of staff files, monthly management reports, etc. The manager confirmed that the home had a current annual development plan: although this was not available for the current year, a previous year’s plan was viewed and incorporated issues relating to outcomes for clients (e.g. activities, staff training, premises, etc.). The home’s health and safety policy was viewed, and contained appropriate information on the responsibilities of the organisation, manager and employees. Staff training in health and safety issues has been noted in the previous section. The manager advised that a requirement identified by the Environmental Health officer last year in relation to food hygiene training had been addressed at the time through staff watching a training video on food safety, and that a number of staff were now enrolled to start a distance learning food hygiene course. The manager maintained records of all checks and servicing carried out on equipment and utilities, which provided evidence that the equipment and premises were regularly maintained. There was no evidence of a current Gas Safety Record certificate in the home: the manager thought that the last certificate may have been kept at their Head Office, and was aware that the next inspection was due. Evidence of this should be maintained in the home. There were records of regular internal checks on hot water temperatures (re risk of scalding and to prevent risk of Legionella), and also evidence of regular fire drills, and checks on fire alarms, emergency lighting, and fire equipment. Accident records were not viewed on this visit. The home had risk assessments relating to a range of safe working practices, including Legionella and use of chemicals. The home had fire procedures and a fire risk assessment; fire safety training was currently in the form of a training video watched by staff, and it is recommended that this be supplemented with other forms of training. A magnetic fire door closure on the seven-side lounge was seen to be broken, resulting in the door having to be propped open: the manager was advised that this should be repaired without delay. Concerns over slow compliance with some environmental health officer and fire officer requirements have been noted under Standard 24. Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 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 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 3 X X 3 X Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES 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 YA3YA35 Regulation 18 Requirement Staff must receive appropriate training to develop their skills in communicating with service users (e.g. Makaton, Total Communication, etc.). Timescale for action 31/05/06 2. YA23 13 This is a repeat requirement for the fourth time, but is still within the previous timescale (31/3/06) 31/03/06 It is required that the home has robust procedures for responding to evidence or suspicion of abuse, which include details of local multi-agency protocols (e.g. referral to social services and the police). This is a repeat requirement for the fourth time, but is still within the previously agreed timescale (extension to 31/3/06 agreed) The registered provider must 31/03/06 review processes for authorising maintenance work on the home, and ensure that urgent repairs and action required by legislation (e.g. statutory requirements by fire officer or environmental health officer) are carried out without delay in future. DS0000040901.V284381.R01.S.doc Version 5.1 Page 24 3 YA24 23 Grammar School House 4 YA28YA24 16 and 23 The registered provider must ensure that immediate action is taken to ensure the dining room is in a safe and suitable state for use. This is particularly with respect to flooring and decoration. 10/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard YA6 YA22 YA23 YA24 YA24 YA24 YA30 YA35 Good Practice Recommendations It is recommended that the home explore alternative formats for care plans and other documents relevant to clients (e.g. pictorial versions, audio, video, etc.). It is recommended that records of complaints received and investigated by the home clearly show the final outcome. The registered person should ensure that all staff have received appropriate training in issues relating to adult abuse and the protection of vulnerable adults. The registered person should ensure that due regard for meeting residents’ needs is taken into consideration when planning any major refurbishment work on the home. It is recommended that the flooring in lounges and corridors is reviewed and replaced as necessary. It is recommended that the decoration, layout and furnishings in the seven-side lounge be reviewed, to see if the lounge can be made more homely. It is recommended that that staff have clear infection control guidance on the appropriate washing cycles for washing linen soiled by body fluids. It is recommended that other forms of training be used to supplement the use of video training in certain subjects (e.g. particularly in relation to POVA, Fire Safety, etc). The registered person should ensure that the type of training provided ensures that staff achieve the required knowledge and competency. It is recommended that LDAF training be implemented within the home as soon as possible. The registered person should progress action to ensure DS0000040901.V284381.R01.S.doc Version 5.1 Page 25 9. 10. YA35 YA35YA42 Grammar School House 11. YA42 that all staff have received up-to-date training in moving and handling. The registered person should ensure that evidence of current servicing of equipment and utilities is maintained in the home. This is particularly with respect to checks carried out on the gas supply and equipment in the home. Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Grammar School House DS0000040901.V284381.R01.S.doc Version 5.1 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. 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