Inspection on 05/10/05 for Grammar School House

This inspection was carried out on 5th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grammar School House 25/10/06

Grammar School House 21/02/06

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 5th October 2005 10:30 Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 1 Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 2 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.V256811.R01.S.doc Version 5.0 Page 3 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.V256811.R01.S.doc Version 5.0 Page 4 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.V256811.R01.S.doc Version 5.0 Page 5 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) 8th February 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 was advised 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.V256811.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 5/10/05, lasting eight hours. The inspection process included: discussion with the manager and three staff; discussion with three clients; the viewing of some communal areas; and inspection of a sample of staff and client records. 19 standards were inspected, and 6 requirements and 8 recommendations have been made. There were 12 people living at the home on the day of the inspection, many of whom were out for part of the day. The clients consulted as part of this inspection were all very positive about the staff team, and about the support and lifestyle provided at Grammar School House. What the service does well: What has improved since the last inspection? The appointment of an activities co-ordinator and the development of a wider range of activities has been a significant area of improvement this year. On this inspection it was noted that clients had full and varied weekly programmes and, where able, had been involved in choosing these. Those spoken to were positive about the activities they were participating in. Although not all care plans were fully completed, the home had made good progress in the development of care plans since the last inspection. The Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 7 majority of these were now fully revised and produced in a new format, and these provided a clear description of the support each person needed to fulfil various aspects of their daily life. These care plans were in well ordered files, with information easy to access and read. A new kitchen had been fitted on one side of the home, and plans were in progress to refurbish the other kitchen and one of the bathrooms. This will significantly enhance the facilities available to those living and working there. 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.V256811.R01.S.doc Version 5.0 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 Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4 The home’s pre-admission process ensures that both the home and the clients can be confident that the home can meet their needs. The home has the facilities and skills to meet the needs of the people it aims to accommodate, but needs to develop staff skills in other methods communication. EVIDENCE: No new clients had been admitted to the home since the last inspection. Evidence of the pre-admission assessment information received for the most recent person admitted to Grammar School House was viewed, and included assessments carried out by the referring agency and the person’s previous home, and also an assessment carried out by the manager of Grammar School House. This provided comprehensive information about the person’s needs. The client had also had opportunity to make several visits to the home prior to deciding to come and live there, including an overnight stay, and there were records for two of these visits describing how the person had got on. Clients spoken to during this inspection were clearly happy with the way staff assisted and supported them. From discussion with staff and the manager, it appeared that staff had a good knowledge and understanding of people’s needs, and provided care and support appropriately. Training records showed that staff had received training in some appropriate and relevant subjects this year (e.g. epilepsy and challenging behaviour), although there was a lack of evidence of staff having current training and skills in moving and handling and in alternative forms of communication. As one client required assistance from Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 10 staff with moving and handling, and many clients had limited verbal communication, these are both areas where staff require further training to meet the needs of clients (see also Staffing section). A good range of appropriate external support was being accessed to meet clients’ needs (e.g. adult education tutor, specialist support from the community learning disability team (physiotherapist, OT, community nurse, etc.), an independent advocate, etc.), which is to be commended. Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 11 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): 6 and 9 Clients’ needs and wishes are clearly reflected in their Individual Plans. The home assesses risks and supports residents to take reasonable risks as part of promoting their independence. EVIDENCE: The home has individual plans (care plans) for each client, describing how their needs are to be met. New care plans had now been implemented for the majority of clients, covering all key aspects of daily life (health, personal care, communication, behaviours, mobility, activities, relationships, etc.). These contained good details of the person’s abilities and needs and the support required from staff, and were clearly written and presented. This showed good progress since the last inspection: only a couple of clients did not yet have a new care plan, and the manager was advised to ensure these are done as soon as possible. Most plans had not been in place long enough to have been reviewed, but reviews were seen on one file and the manager confirmed that care plans would be reviewed at least six monthly. . The home had not yet explored alternative formats for care plans, but the manager stated that the clients who could read had seen their plans. It was Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 12 suggested that clients could be asked to sign their care plans to show their involvement in these. The home operates a key worker system, and clients spoken to were aware of who their key worker was, and of the roles of manager and key workers. Each care plan had an accompanying risk assessment, which identified any risks relating to that issue (e.g. travelling in the minibus, bathing, etc.), and showed the action to be taken to minimise the risk. Staff spoken to described the risks to staff associated with one client’s behaviour, and the strategies adopted to minimise these. Where clients were able to communicate verbally, there was good communication between them and the staff, and choices were discussed with them. Training in personal safety was not discussed on this occasion. Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 13 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): 12, 13, 14, and 16 The home enables and supports clients to take part in appropriate activities (including leisure activities), and to access opportunities and facilities in the local community. Staff respect clients’ right to privacy and choice, and encourage responsibility for tasks within the home. EVIDENCE: The home has appointed a part-time activities co-ordinator: the manager and staff were very positive about this person’s role, and felt that this has enabled a much wider range of activities to be provided in the home. This appeared to be a good initiative on the part of the home, and the weekly activities programme showed that clients were all engaged in a variety of rewarding educational and leisure activities, supported by staff as required. Clients spoken to were positive about their current activities, and it was noted that most of them were out at some point during the inspection day. Activities included courses at a variety of colleges and in the home (an adult education tutor came in three days a week), activities utilising other community resources (e.g. leisure centre for swimming and trampolining; horse riding; exercise class at the local village hall; attendance at some local day centres Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 14 and at evening clubs, etc.), and time spent with staff both going out (e.g. pub lunch, shopping, outings, etc.) and in the home (e.g. time with key workers, using the snoozelem room, etc.). One client was also attending some work experience in a garden centre. Due to the village location of the home, clients generally used transport provided by the home, but it was clear that the home made good use of facilities in the local community (e.g. shops, church, car boot sales, pubs, etc.). Staff felt that staffing levels were generally satisfactory for supporting activities, and clients only reported limitations to their activities at times when there were insufficient mini-bus drivers available. During the inspection it was clear that clients were able to make choices about their daily lives, especially in relation to activities, meals, and where and how they wanted to spend their day. They were able to choose to spend time alone in their own rooms, and (where able) could have a key to their room. Daily routines were flexible, and where clients could not communicate verbally, staff showed a good awareness of how they expressed their wishes or dislikes. Staff were seen talking with clients, and interacted well with them. In the annex, clients had responsibility for certain daily tasks; whether this was recorded in their individual plan was not inspected on this occasion. Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 15 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): 18, 19 and 20 At the time of this inspection, personal support was provided in a way that met clients’ preferences and needs, and the home was meeting clients’ health needs appropriately. The home’s medication practices provided safe systems of storage and administration, supported by accurate records. EVIDENCE: Clients spoken to were happy with the support given to them by staff. Individual Plans clearly described what support each person needed with personal care and mobility, and how staff should give this (reflecting service users likes, wishes and preferences). Clients spoken to were happy with their key worker, and clients’ wishes and needs had been taken into account when matching them with key workers. It was clear that key workers encouraged and assisted clients to make their own choices regarding hairstyles and clothing, or made choices based on their knowledge of a person’s likes and personality. Files showed contact with GPs and nurses for healthcare needs, and it was noted that a chiropodist was visiting the home at the time of the inspection. From discussion with the manager it was evident that the home sought appropriate specialist support for clients, and assisted them to attend appointments when necessary. A wide range of external support was accessed Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 16 including psychiatrist, psychologist, community outreach team (community nurse, speech and language therapist), dietician, etc. The community learning disability nurse had been assisting the home in the development of epilepsy care plans. The home had appropriate equipment to meet individual needs (e.g. wheelchair, hoist, etc.). The home’s medication policy was not inspected on this occasion. Storage arrangements were viewed: it was noted that the home had installed a new medication cabinet, and medication was being appropriately stored. The home also has a controlled drugs cabinet, but staff reported that no controlled drugs were currently in use. A pharmacist had visited the home this year to view storage and administration arrangements. No clients were able to manage their own medication. The manager, one carer and two of the four senior staff had completed an open learning medication course this year, which comprehensively covered all aspects of medication practices; one other carer had attended medication training in 2004. Competence to administer medication was assessed internally by senior carers or the manager: the manager was advised to ensure that all seniors assessing other staff competence have been appropriately trained, and to ensure that all staff administering medication have completed formal medication training. Medication was dispensed to the home in a Monitored Dosage System, with Medication Administration Record (MAR) forms supplied by the pharmacist to show each prescribed medication and dose. Medication received by the home was being checked on receipt, and recorded on the MAR; if no new medication had been supplied, staff were now clearly recording any medication carried over from the previous month. Changes to administration instructions entered by staff were being signed and dated: in one instance it was not clear why a change had been made, and the manager was advised to ensure that there is always a clear reference to who authorised the change and when. Records of medication administered were well completed. Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 17 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): 23 The home has information and policies that promote the protection of vulnerable adults. EVIDENCE: The home has a policy on the protection of vulnerable adults (POVA): this was not viewed on this visit as the manager confirmed that no changes had been made since the last inspection. It had been noted at previous inspections that information on the home’s procedure for responding to suspicion or allegation of abuse was quite brief, and did not contain any details of the Essex multiagency procedures established in accordance with the Department of Health’s ‘No Secrets’ guidance. The home had a training video on POVA and records showed that seven care staff had seen this, and that three staff had attended other POVA training; two other staff told the inspector that they had attended training in their previous jobs, and the staff spoken to were aware of what action to take if they had concerns about abuse taking place. There was not evidence of POVA training for all staff, and the manager was advised to ensure that all staff receive suitable POVA training. The manager was applying to do a POVA trainer’s course. Records showed that eight staff had attended training in challenging behaviour earlier this year, and a further three had watched a training video on this. Records showed that incidents of challenging behaviour were recorded and monitored, and that appropriate strategies for managing these were detailed in risk assessments and care plans. Appropriate action was being taken to understand and support clients who self-harmed. Policies and practices for managing clients’ monies were not inspected on this occasion. Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Clients’ toilets and bathrooms provided privacy and met their individual needs. EVIDENCE: Most of the environment standards were not inspected on this occasion, but action taken to meet issues identified at the previous inspection was discussed with the manager. It was noted that one of the kitchen’s had been refurbished, and the manager confirmed that work was due to take place on the other kitchen soon. She also confirmed that new suites had been ordered for both lounges, as had some new beds for clients. The manager stated that the annex bathroom had been repaired, but needed further action; vanity units in bedrooms had not yet been replaced. Bathrooms were not viewed on this occasion. The home continued to maintain the number of bathrooms present in the home prior to the implementation of the Care Standards Act i.e. two bathrooms (one on each side of the home), both containing a standard bath and toilet, with an additional shower cubicle in the Annexe bathroom. There is a additional toilet on both sides of the home, and one bedroom in the Annex has an ensuite toilet and shower. Although the bath on the Seven-Side of the home can be used in conjunction with a hoist, the manager stated that funding has been agreed to convert this bathroom Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 19 into a fully assisted bath and shower room. During discussion with staff on this inspection they highlighted that one bathroom is often insufficient to meet the needs of the seven clients on the seven-side: most of these have daily baths, all need supervision or support from staff, and some require additional assistance with personal hygiene during the day due to continence needs. Staff reported sometimes having to wait some time to be able to access the bathroom. The provider should review the needs of clients in the home to determine whether arrangements need to be made to provide additional bathing facilities. Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 24, 35 and 36 The home has a competent and qualified staff team, who effectively meet most areas of clients’ needs; however, some further training was needed to ensure that staff are satisfactorily trained to meet all clients’ needs. The home operates safe recruitment practices that support and protect clients. The staff team are well supported through day-to-day management practices, but formal supervision needed further development. EVIDENCE: The home had continued to maintain staffing levels of five staff throughout the day (two in the Annex, and three on the Seven-Side) and two at night, and had also appointed a part-time activities co-ordinator this year. Rotas viewed showed that staffing levels were being consistently maintained, with only occasional days when a shift was one person short. Staff reported finding it more difficult to manage when shifts were one short. The home had recently appointed a part-time administrator, and the manager was finding this assistance helpful to the running of the home. Specialist support had been obtained from other professionals where necessary. Staff (and service users) had still not received training to develop communication skills (e.g. Makaton, Total Communication training, etc.), although the manager’s ongoing efforts to access this training were noted. Although most staff knew some basic Makaton, this skill needed further development within the staff team. Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 21 Two staff had been recruited since the last inspection: one file inspected showed that an appropriate recruitment process had been followed, with all the required checks carried out prior to the person starting work; the person had also received a contract of employment and a copy of the General Social Care Council code of conduct. The manager reported that during the interview process, clients had spent time with the candidate and asked their own questions; they had given the manager verbal feedback afterwards, and it was recommended that this be recorded in future. The manager stated that CRB checks had been carried out on other professionals working with clients in the home (e.g. chiropodist and reflexologist), which is good practice. The induction process for new staff included a period of time working alongside other staff, and an induction checklist covering the TOPSS induction units that the manager worked through with the new staff member. The manager stated that LDAF training has not yet been implemented in the home, and was recommended to progress this as soon as possible. Staff spoken to showed appropriate knowledge and attitudes, were motivated and committed, and appeared comfortable with clients, relating well to them. Training records showed that of the thirteen care staff (excluding bank staff and activities co-ordinator), eight had already attained NVQ level 2 or above; this meets the standard for at least 50 of staff to be trained to this level by 2005. Evidence of other training completed this year included workshops on epilepsy, loss and bereavement and challenging behaviour, plus the internal use of videos to provide information on a range of other subjects including fire safety, POVA, first aid, food hygiene and challenging behaviour. Where training was only provided through videos, the manager was advised to ensure that these provided staff with sufficient knowledge and competency in these subjects, and to arrange other forms of training if necessary. For most staff there was no evidence of recent moving and handling training, and the manager was advised that this should be arranged as soon as possible. There was also no evidence that any staff had attended first aid training, and the manager was reminded that there should be a trained first aider on each shift (reference Standard 42.2). The manager was maintaining good individual and central training records, and was in the process of developing a Workforce Planning Framework, identifying team and individual training needed for all staff. Many staff had not attended the equivalent of five paid training days in the last year (one person had only one training session recorded), and this should be monitored. The home aims for all staff to receive formal one-to-one supervision every two months, plus an annual appraisal. Records showed that this was not being achieved in the case of most staff, and some staff had received very little formal supervision this year. Supervisions are carried out by the manager and by senior staff; senior staff had not received any specific training in carrying out supervision. Staff meetings were held regularly throughout the year, with Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 22 clear minutes kept. The home was in the process of establishing an experienced senior team, and the manager was working alongside staff in the home at least one day a week. Staff spoken to during the inspection felt well supported by both the manager and other colleagues, and were positive about the manager, saying that she was always available to them, and was approachable and helpful. Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 23 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): None EVIDENCE: None of these standards were specifically inspected on this occasion. With regard to previous requirements, the manager confirmed that new thermostatic control valves had been fitted to hot taps to ensure that hot water could be maintained at a safe temperature for service users. She also confirmed that the home has systems in place to monitor and control the risk from Legionella, including an annual check by an external company and six monthly checks by the home’s maintenance person. Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 2 3 X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X 2 X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grammar School House Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000040901.V256811.R01.S.doc Version 5.0 Page 25 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 Regulation Requirement Staff must receive appropriate training to develop their skills in communicating with service users (e.g. Makaton, Total Communication, etc.). This is a repeat requirement for the third time (previous timescale 31/7/05). The registered person must ensure that all staff administering medication receive appropriate training. Staff who assess the competence of other staff must be fully trained. It is required that the home has robust procedures for responding to evidence or suspicion of abuse, which include details of local multiagency protocols (i.e. referral to social services and the police). This is a repeat requirement for the third time (last timescale 31/3/05) The registered person must ensure that all staff have received up-to-date training in moving and handling. DS0000040901.V256811.R01.S.doc YA3YA32YA35 18 Timescale for action 31/03/06 2 YA20YA35 13 and 18 30/11/05 3 YA23 13 30/11/05 4 YA35 13 and 18 31/12/05 Grammar School House Version 5.0 Page 26 5 YA35YA42 12 and 18 6 YA36 18 The registered person must ensure that sufficient staff in the home have completed first aid training. The registered person must ensure that all staff receive appropriate supervision (see also recommendation 8). 31/12/05 31/10/05 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 2 3 4 5 Refer to Standard YA6 YA6 YA23 YA27 YA35 Good Practice Recommendations It is recommended that the registered manager ensure that all clients’ care plans are updated as soon as possible. It is recommended that the home explores alternative formats for care plans and other documents relevant to clients (e.g. pictorial versions, audio, video, etc.). The registered person should ensure that all staff have received appropriate training in issues relating to adult abuse and the protection of vulnerable adults. It is recommended that the registered provider review whether current bathing facilities are sufficient to meet the needs of clients. 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 is implemented within the home as soon as possible. It is recommended that the registered person ensure that all care staff attend at least 5 paid training days per year. It is recommended that all staff receive a minimum of six recorded supervision meetings per year. Staff carrying out supervision should be appropriately trained to do so. 6 7 8 YA35 YA35 YA36 Grammar School House DS0000040901.V256811.R01.S.doc Version 5.0 Page 27 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.V256811.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!